. HX64055582 RD35 Ei8 Surgical diagnosis, RECAP RJ^^s tiB (Sift nf ir. Snsppii A. llakr Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/surgicaldiagnosiOOeise Surgical Diagnosis BY DANIEL N. EISENDRATH, A.B., M.D. ADJUNCT PROFESSOR OF SURGERY IN THE MEDICAL DEPARTMENT OF THE UNIVERSITY OF ILLINOIS (COLLEGE OF PHYSICIANS AND SURGEONS); ATTENDING SURGEON TO THE MICHAEL REESE AND COOK COUNTY HOSPITALS, CHICAGO WITH FOUR HUNDRED AND EIGHTY-TWO ORIGINAL ILLUSTRATIONS, FIFTEEN OF THEM IN COLORS PHILADELPHIA AND LONDON W: B. SAUNDERS COMPANY 1907 Copyright, 1907, by W. B. Saunders Company PRINTED IX PHILADELPHIA PREFACE. A recognition of the necessity of making a correct diagnosis before instituting treatment has prompted me to write this treatise. I have omitted the diagnosis of affections of the eye, ear, nose, throat, and skin, since these are so fully considered in the special treatises upon these sub- jects. The only exceptions are the intracranial complications of middle ear and mastoid disease and those affections of the upper respiratory tract which require major surgical intervention. The question of diagnosis has been approached chiefly from the clinical standpoint. An attempt has been made to group injuries and diseases in the manner in which the surgeon or general practitioner must consider them when he examines a patient for the purpose of making a diagnosis. Thus, in the chapter upon injuries of the head, the various traumatic lesions of the scalp, skull, and brain are considered together. In the chapter upon the abdomen the injuries of all of the abdominal vis- cera are taken up in a similar manner. The division of diseases of the abdomen into acute abdominal affec- tions, abdominal tumors, and a further description of the remaining surgical conditions of the abdominal viscera, may occasion some criticism. In making such an apparently arbitrary classification I have had in mind the clinical picture as one encounters it at the bedside. Although such divisions are not appropriate for a text-book which includes pathology and treatment, they seem most practical for a book limited to diagnosis. The same principle has been applied throughout. The importance of differentiation of affections which simulate each other has been con- stantly borne in mind, repetition being avoided as much as possible. The necessity of making a diagnosis at an early period for the purpose of instituting prompt surgical intervention, is frequently referred to. Much attention has been paid to the description of methods of examina- tion, and this has been aided wherever possible by illustrations. Being ^ strong advocate of the teaching of surgery by the education of the eye, I have introduced a large number of original illustrations of clinical cases and specimens. I am indebted to my colleagues upon the staffs of the Cook County and Michael Reese Hospitals for the privilege 9 lO PREFACE. of photographing many of their patients. I desire to thank Drs. I\I. L. Blatt and F. Baumann for valuable suggestions. The section upon methods of blood examination was written by Dr. D. L. Schram. The section upon cystoscopy and ureteral catheterization was written by Dr. Gustav Kolischer. Daniel N. Eisendrath. April, 1907. CONTENTS CHAPTER I. PAGE Surgical Affections of the Head 17 Injuries of the Scalp, Skull, and Brain 17 Injuries of the Scalp 17 Fractures of the Skull 22 Concussion of the Brain , 35 Compression of the Brain 36 Cerebral Contusion or Laceration 42 Cerebral Localization 44 Intracranial Hemorrhage 48 Differential Diagnosis of Injuries of the Brain 54 Pachymeningitis Hsemorrhagica Interna 55 Intracranial Suppuration Following Injuries 55 Contusions of the Cranial Bones 61 Hernia Cerebri 62 Traumatic Epilepsy 62 Mental Conditions Following Cranial Injury 64 Diseases of the Scalp, Skull, and Brain 65 Diseases of the Scalp 65 Non-traumatic Surgical Diseases of the Brain and its Envelopes 73 Intracranial Complications of Middle Ear and Mastoid Suppuration 80 Injuries and Diseases of the Face r 86 Injuries of the Soft Parts of the Face 86 Injuries of the Bones of the Face 87 Diseases of the Soft Parts of the Face 9^ Diseases of the Mouth and Palate 103 The Lips 104 Diseases of the Jaws 108 Tumors 108 Infections 1^7 Diseases of the Temporo-maxillary Joint 122 Diseases of the Mouth 123 Stomatitis 123 Syphilis ^-4 The Diagnosis of Conditions at the Floor of the Mouth 124 Tumors of the Inside of the Cheeks 127 Tumors of the Palate ^27 The Tongue 127 Affections of the Salivary Glands 138 CHAPTER II. Surgical Affections of the Neck i47 Congenital and Acquired Malformations i47 12 CONTENTS. PAGE Injuries of the Neck 152 Foreign Bodies in the Air Passages 156 Inflammatory Processes 157 Infection of the Superficial Structures of the; Neck 160 Affections of the L}Tnph-nodes of the Neck 162 Tumors of the Neck 172 Cystic Tumors 174 Solid Tumors 178 Non-malignant Goiter 185 Malignant Goiter 187 Thyroiditis 188 Exophthalmic Goiter 189 Edema of the Glottis 190 Papilloma of the Lar\-nx 190 Carcinoma of the Lar}mx 191 CHAPTER III. Thorax 193 Injuries of the Bony Walls of the Thorax 193 Fractures of the Ribs 193 Fractures of the Costal Cartilages 194 Fractures of the Sternum 194 Injuries of the Thoracic Viscera 195 Non-penetrating or Subcutaneous 195 Penetrating Injuries of the Thorax Proper 199 Acute and Chronic Infiammators' Processes of the Thoracic Wall 201 Of the Skin and Subcutaneous Tissues 201 Affections of the Bony Thorax 202 Tumors of the Chest Wall 206 Empyema 208 Tumors of the Pleura 212 Pulmonary Abscess, Gangrene, and Bronchiectasis 213 Echinococcus of the Lungs 216 Actinomycosis of the Lungs and Pleura 216 Tvunors of the Lungs 217 Suppurative Pericarditis 217 Affections of the Mediastinum 218 Inflammator}' Processes 218 Tumors 219 Foreign Bodies in the Air Passages •. 220 Diseases of the Breast 221 Inflammatory Processes 221 Tuberculosis 225 Hypertrophy 227 Neoplasms 227 CHAPTER IV. Abdomen- 231 Affections of the Abdominal Wall 231 Inflammatory Processes 231 Tumors ■ - - 233 Congenital Conditions 235 CONTENTS. 13 PAGE Abscesses 'Discharging through Umbilicus 236 Tumors of the Umbilicus 236 Injuries of the Abdominal Walls and Viscera 237 Acute Abdominal Affections 245 Acute Cholecystitis 246 Hepatic Infections 248 Primary Forms of Peritonitis 250 Renal Infection 251 Subphrenic Abscess 253 Suppurating Echinococcus Cysts of the Liver 254 Pericolitis Sinistra 255 Multiple Abscesses of the Omentum 255 Appendicitis 256 Gallstone Colic 264 Perforations of Ulcers of the Stomach or Duodenum 266 Acute Pancreatitis 270 Renal Colic 270 Dietl's Crises 271 Embolism and Thrombosis of the Mesenteric Vessels 272 Torsion of the Pedicles of Ovarian and Uterine Tumors 273 Torsion of the Spermatic Cord 274 Visceral Crises 274 Angina Sclerotica Abdominis 276 Referred Pain from Spinal and Thoracic Conditions 276 Inflammation of the Intraabdominal Portion of the Vas Deferens 276 Acute Intestinal Obstruction 277 Ruptured Extrauterine Pregnancy 284 Abdominal Tumors 285 Tumors of the Stomach 289 Tumors of the Liver 291 Tumors of the Gallbladder 297 Tumors of the Pancreas 299 Tumors of the Spleen 304 Tumors of the Intestines 307 Tumors of the Peritoneum and Mesentery 310 Tumors of the Kidney ■ 311 Ascites 318 Tumors due to Inflammatory Exudates or to Tuberculous Peritonitis 320 Tumors due to Aneurysms of the Abdominal Aorta or its Branches 321 Tumors of the Abdomen having their Origin in the Pelvic Viscera or Bones. 323 Diseases of the Esophagus 324 Stricture 324 Diverticula 329 Idiopathic Dilatation .- 330 Foregin Bodies 330 Other Abdominal Conditions 331 Surgical Diseases of the Stomach, 331 Gallstones 337 Appendicitis (Chronic) 34° Chronic Intestinal Obstruction 341 Tuberculous Peritonitis 343 The Rectum 345 14 CONTENTS. PAGE Methods of Examination 345 Congenital Malformations 346 Injuries 347 Foreign Bodies 348 Inflammatory Processes 349 Hemorrhoids 355 Prolapse 356 Strictures 357 Neoplasms 359 Renal and Vesical Lesions 361 Older and Newer Methods of Diagnosis 361 Pyelitis 362 Tuberculosis of the Kidney 363 Diagnosis of Renal Calculi 365 The Bladder 371 Congenital Malformations 371 Wounds 372 Inflammation 372 Tuberculosis 374 Calculi 375 Tumors 376 Affections of the Prostate 377 Enlargement 377 Injuries and Diseases of the Urethra and Penis 379 Congenital Malformations 379 Contusion and Rupture of the Urethra 380 Localization of Pus in the Lower Portion of the Male Genito-urinary Tract. . . 381 Phimosis 385 Paraphimosis 385 Balanitis 385 Epithelioma of the Penis 386 The Testes 387 Abnormalities in Development 387 Imperfect Descent and its Complications 388 Infections of the Male Reproductive Organs 391 Traumatic Affections 393 Tuberculosis 393 Syphilis 398 Tumors of the Testis and Epididymis 399 Spermatocele 399 Neoplasms of the Testis 399 Hernia 401 Inguinal Hernia 404 Femoral Hernia 414 Umbilical Hernia 417 Ventral Hernia 420 Rarer Forms of Hernia 42 1 CHAPTER V. The Extremities 422 Injuries of the Soft Tissues, Bones, and Joints, 422 Injuries of Muscles, Tendons, and Tendon-sheaths 424 CONTENTS. 15 PAGE Injuries of Blood-vessels 429 Injuries of Nerves 433 Injuries of Individual Nerves 435 General Considerations upon Injuries of the Bones 43^ General Considerations upon Injuries of the Joints 45° General Considerations upon Dislocations 45^ Special Fractures and Dislocations 461 Complications of Injuries 5^5 Shock and Hemorrhage 5^5 Traumatic Delirium and Delirium Tremens 528 Infective Complications of Wounds 529 Surgical Diseases of the Extremities 544 Affections of the Skin and Subcutaneous Tissues 544 Surgical Diseases of the Skin 554 Diseases of the Arteries 557 Diseases of the Veins 5^^ Diseases of the Lymph-vessels 5^3 Diseases of the Lymph-nodes 5^5 Diseases of the Bursae 5^^ Diseases of the Tendons and Tendon-sheaths 567 Diseases of Muscles 57° Diseases of the Fascije 573 Diseases of the Nerves 573 Diseases of the Bones 575 Diseases of the Joints in General 601 Diseases of the Individual Joints 627 Diseases of the Knee-joint 639 Diseases of the Ankle-joint 644 Deformities 646 CHAPTER VI. Diseases and Injuries of the Spine 662 Spina Bifida 662 Injuries of the Spine 664 Spinal Localization 666 Diseases of the Spine 684 Tuberculous Spondylitis (Pott's Disease) 684 Scoliosis (Lateral Curvature of the Spine) 690 Arthritis Deformans (Spondylitis Deformans) 691 Acute Osteomyelitis 69 1 Typhoid Spine 692 Hysterical Spine 692 Tumors of the Spine and Spinal Cord 692 Sacrococcygeal Tumors 695 CHAPTER VII. Postoperative Complications 696 Hemorrhage 696 Shock and Collapse , 699 Infection 700 Pulmonary Complications 701 l6 CONTENTS. PAGE Cardiac Complications 702 Hepatic Complications 703 Gastric Complications 704 Postoperative Ileus 707 Postoperative Peritonitis 708 Renal Complications 709 Circulatory Complications 710 Miscellaneous Complications 711 Diabetic Complications 712 Postoperative Parotitis 713 Status Thymicus 713 Acute Thyroidism 714 Postoperative Hysteria 714 CHAPTER VIII. Methods of Examination 715 Examination of the Blood in Surgical Cases 715 Differential Leukocyte-count 715 Opsonins and the Opsonic Index 716 Leukopenia, Leukocytosis, and Hyperleukocytosis 720 Value of the Differential Leukocyte-count 725 Pernicious Anemia 728 Leukemia 728 Estimation of Blood-pressure in Surgical Cases ' 729 Cytddiagnosis : 731 Examination of the Sputum, Stomach Contents, Urine, and Feces 732 The Newer Methods of Diagnosis of Renal Lesions 732 Index 75: Surgical Diagnosis. CHAPTER I. SURGICAL AFFECTIONS OF THE HEAD. Injuries of the Scalp, Skull, and Brain. For clinical purposes the scalp can be considered as composed of three layers (Fig. i), viz., the outer or cutaneo-aponeurotic, the middle or subaponeurotic, and the inner or pericranial. In infants the last- named layer or pericranium is loosely attached to the skull, except along the sutures, while in the adult it is so firmly attached over the entire vertex that it can be torn off only with difficulty. INJURIES OF THE SCALP. These occur either in the form (a) of penetrating, i. e., lacerated, incised, or punctured wounds, which may penetrate one or more of the layers, or (b) appear as contusions with swelling of these layers caused by extravasation of blood, or (c) the two forms may be combined. Penetrating Wounds. — ^The diagnosis of these is readily made by inspection, which should be preceded by shaving the scalp for a dis- tance of at least three inches from the edges of the wound. The chief point of interest is to ascertain whether they simply extend (a) through the skin and subcutaneous tissue, or (b) through the aponeurosis. Wounds of the former class never gape, while in those of the latter class the edges separate. Retraction of these edges will enable one to determine whether the wound also involves the pericranium and skull. It cannot be too strongly emphasized that the greatest care should be exercised to render aseptic not only the scalp itself, but also the hands of the examiner and the instruments to be employed, before an explo- ration of the depth and possible comphcations of a scalp wound are begun. The injury of the larger arteries of the scalp can be suspected when the hemorrhage is profuse and of a spurting character, especially 2 17 15 SURGICAL AFFECTIONS OF THE HEAD. when the wounds are situated close to the frontal, temporal, or occip- ital arteries. Contused Wounds of the Scalp. — ^The diagnosis of these must be made from a consideration of the age, the history, and the local findings. They may be quite superficial, causing only shght swelling and discoloration of the skin, or deeper, resulting in quite visible tumors (Fig. i). The diagnosis of the former presents no difficulties. In the deeper or more severe form anatomical pecuharities play a role. In infants and young children contusions of the scalp are often followed by marked swelling. This is especially the case in infants following a difficult labor, where considerable pressure has been exerted upon the head by instruments or by the bony pelvis. Fig. I.— Location of Various Hemorkhages in the Scalp. SK and AP represent the cutaneo-aponeurotic layer; P, pericranium; S, skull; i, superficial hematoma or contusion in skin proper of scalp; 2, hemorrhage or pus-formation in subaponeurotic layer; 3, subpericranial hemorrhage. The latter is the location of the hemorrhage in the cephalhematoma of infants. Such swellings are called ce phalhematomata , and are the result of an extravasation of blood between the pericranium and the skull (Fig. i). The pericranium, as was stated above, is loosely attached except along the sutures; hence the diagnostic features are that these cephalhemato- mata are situated over one or both parietal bones (Fig. 2), and can be followed until they terminate at the sutures (either coronal, sagittal, or lambdoidal). They fluctuate, but do not pulsate or increase in size when the child cries. The absence of the latter two features in ceph- alhematomata and the fact that meningoceles almost always occur in the frontal or the occipital region enable one to differentiate these two conditions in the scalps of young infants. At a later period (four to six weeks) a zone of ossification often begins at the edge of a ceph- INJURIES OF THE SCALP. 19 alhematoma, and, in the absence of the history, a fracture might be thought of. The hmitation of the swelhng by the sutures, the distinct fluctuation to be obtained, and the fact that pressure does not reveal any defect in the skull or cause any cerebral symptoms, enable one to exclude a fracture. A cephalhematoma may at times occur without the history of injury in scorbutic and rachitic children, and be mistaken for an abscess following tuberculosis of the cranial bones. It would seem advisable in connection with the subject of cephalhematoma in infants and young children to call at- tention to a swelling which may produce a considerable elevation of the overlying intact scalp. This swelhng follows an injury to the scalp and skull in children in the first three or four years of life, and is called traumatic cephalhydrocele (Fig. 3) or meningocele spuria trau- matica. The injury may have been accompanied by symp- toms of cerebral concussion or contusion, but at times cases present themselves years after such an injury, or the latter has been so insignificant that no importance is ascribed to it. Such swellings may appear over any part of the vertex of the skull, and are due to the accumulation of cerebrospinal fluid between the scalp and the skull, which has escaped through an opening following a fracture. These swellings have, as a rule, a pulsation which is synchronous with that of the heart, but cases have been recorded where there is no pulsation. The swelhng can be reduced, and when this is done, the edges of the skull opening can be felt. Often such a reduction causes compression symptoms. These spurious or false meningoceles must be differentiated from the follow- ing conditions : I. Deep cavernous angiomata. These may show distinct fluctuation ^ .^^^^^m^ ^ ^1 f ^K^- -^ 1 j|LjHH|^||QgEgM| 1 1 1 1 Fig. 2. — Cephalhematomata of Newborn Child. I, Hematoma over right parietal bone; 2, hematoma over left parietal bone. 20 SURGICAL AFFECTIONS OF THE HEAD. and pulsation and can be decreased in size by compression, but firm pressure upon the veins leading to them will cause all these signs to dis- appear. In addition there is no peripheral elevation of bone, and no defect in the skull can be felt. 2. Hematomata or blood- cysts beneath the pericranium, following fractures of the skull, which communicate with the longitudinal or lateral sinuses. They are often called sinus pericranii, and are quite rare, only ten cases having been reported. They are more prominent when the patient bends forward, and are due to the rupture of an emis- sary vein which does not heal and which communicates with a sinus. 3. Congenital meningocele and encephalocele. These have a somewhat constant location in the frontal or the occipital region; there '%MIII§^r^--'j0m, Fig. 3. — Meningocele Spuria Traumatica CBayertlial). is an absence of a history of injury, and the defect in the skull is round and smaller than the tumor itself. 4. Soft sarcomata of the dura which form subcutaneous tumors after penetrating the skull. These may pulsate, and can be reduced by pressure, but do not fluctuate, and there is usually a history of gradual growth without preceding trauma. In older children and in adults, contusion of the scalp may be fol- lowed by a hematoma in the subcutaneous tissue, forming a swelHng which can be moved upon the skull (superficial hematoma), or it may result in the escape of a larger or smaller quantity of blood into the subaponeurotic layer (Fig. i). As was stated above (see page 17), the pericranium in the adult is so firmly attached to the skull that the INJURIES OF THE SCALP. 21 escape of blood beneath it is not sufficient to be recognized, in the absence of a penetrating wound. A subaponeurotic or deep hematoma often follows a severe contusion of the scalp. Its edges are frequently firm and elevated and its center depressed, resembling under these con- ditions a depressed fracture of the skull. By passing the finger firmly from the surrounding uninjured scalp across the peripheral elevation, one will find that the latter is above the level of the skull (Fig. 4) and can be pressed away. The edges of such a hematoma lack the hardness of the skull bone and also the sharp outline of a fractured bone. In some cases, especially when there is an accompanying coma of uncertain origin and non- surgical conditions have been ehminated, the diagnosis of a simple contusion of the scalp is perplexing and justifies an exploratory incision carried out under proper precautions. The diagnosis becomes espec- ially difficult when the patient is seen several days after the injury, and an infection of the hematoma has begun (see page 66). The hematoma may be quite extensive and communi- cate with a ruptured artery of the scalp, causing distinct pulsations (pulsating hema- toma). At times after a fracture of the vertex, especially in children, a large hematoma will form without a scalp wound, but accompanied by symp- toms of compression (see page 36). In one case observed by the author there was a direct communication between the scalp hematoma and a ruptured middle meningeal artery. The compression symptoms are the only means of diagnosing such an injury, and in their absence it would be impossible to trace any relation between a large hematoma of the scalp and intracranial hemorrhage. n lL — 1 Bone A mj( ^^^ 1 J Pt Soft center of hemato- ma \'l ' • \ \ [ard edge of hematoma 11 fe\ -4- ! Brain i J Fig. 4. — Hematoma of Scalp, the Soft Center and Firm Edge of which often Simulate Fracture (Scudder). 22 SURGICAL AFFECTIONS OF THE HEAD. FRACTURES OF THE SKULL. The diagnosis of a fracture of the skull must be based upon a con- sideration of the following points : I. The history of the mode of injury. II. The direct examination of the vertex. III. The interpretation of certain special signs indicating fracture of the base. IV. Evidences of injury of the intracranial structures. L History of the Mode of Injury. At the time of the accident this is of subordinate value, because a careful estimate of the evidence obtained from the other three factors will usually enable a diagnosis to be made. At a later period, however, the possibihty of a fracture having been the result of a certain mode of injury may arise, and an exact history should be obtained. In general, fractures of the skull are produced by a force acting in one of two ways : First, upon some one point in the skull; for example, a blow with a hammer, a bayonet, or a bullet. A fracture is far more likely to occur where the force acts thus on a circumscribed area than in the second variety, where it is distributed in meridians radiating from the point of impact, and perhaps producing a fracture at some distant point, where the elasticity of the bone yields. A fall upon the vertex, the feet, or the buttocks is an example of a force acting thus in a more diffuse manner and, as a rule, a fracture is not so Hkely to follow it. The history of a gunshot or a punctured wound of the mouth or orbit is of aid in diagnosing a fracture of the base. The history may be of some confirmatory value in the following instances: (a) Where a hematoma of the scalp (see page 21) resem- bles a simple depressed fracture. Here the history of some force apphed in a concentrated manner should lead one to examine for other evidences of fracture, such as those of intracranial injuries, (b) Where bleeding from the nose and ears and other signs of basal fracture exist without coma, etc. A fall upon the vertex may by transmission of force produce a fracture at the base by meridional distribution and such a history will be of aid in confirming the above evidences of a fracture of the base, (c) When Jacksonian epilepsy has developed, the likelihood of a frac- ture having been sustained at the time of injury is greater if there is a history of a blow having been struck by some instrument or missile (e. g., mallet, iron bar, a rock, etc.) capable of producing a .circum- scribed injury. FRACTURES OF THE SKULL. 23 II. Examination of the Vertex. This must be made under one of two conditions : (a) Where no open wound exists as a result of tlie accident, as is the case in simple fractures; (&) where a wound of the scalp leads either directly or indirectly to the seat of the fracture, as in compound fractures. (a) Where no Scalp Wound is Present. — Under these circumstances our only method of diagnosis from an examination of the skull lies in direct palpation of a lissure or of a depression. In the case of a fissure this is usually impossible unless the fissure is very wide, and Fig. s. — Simple Depressed Fracture of the Skull in an Infant, without Symptoms. No Treat- ment. Gradual Disappearance of Depression (Elliot's Case). in the absence of more direct evidence of intracranial injury is abso- lutely unreliable as an aid to diagnosis. In the case of a depression apparently in the vertex, which can be felt by passing the finger over the intact scalp, the following conditions must be excluded before a diagnosis of depressed fracture s'hould be made. 1. The possibihty of a hematoma of the scalp resembling a depressed fracture (see page 21). 2. Normal depressions in the adult skull, especially in the aged. One should always compare the two sides of the skull a number of times when palpating it through the intact scalp. 3. Depressions due to congenital defects, e. g., meningocele. 24 SURGICAL AFFECTIONS OF THE HEAD. 4. Depressions due to the presence of Wormian bones. 5. Depressions following the softening of syphilitic gummata with thickening of the periosteum at the edges of such a depression. 6. Depressions due to pressure on the head by the bony pelvis or by forceps during birth. Such depressions can occur in the infant's skull, owing to its great elasticity, and upon first examination feel hke a depressed gutter fracture. They rarely persist, but correct themselves spontaneously within a few weeks (Fig. 5). In a case of depressed fracture occurring without scalp injury Fig. 6. — Location of Most Frequent Lines of Fissured Fraci'URE of the Sk'ull, Extending into THE Base. Fissure extending through temporo-parietal bone into middle fossa; 2, fissure extending through occipital and temporal bones into base of skull, the petrous portion of the temporal bone. the palpation of the irregular sharp edges of the bone will serve to distinguish it from the smooth edges of a congenital defect. The frequent location of the congenital defects in the parietal and occip- ital bones, will also be of aid. In a case of depression following syphilis the history and the pres- ence of other evidences of the tertiary stage will clear up the diagnosis. At the present time the surgeon should never be content with making a diagnosis of depressed fracture of the vertex without a visual inspec- tion of the skull through an exploratory incision made under proper precautions. FRACTURES OP THE SKULL. 25 (b) Examination 0} the Vertex where a Wound 0} the Scalp Exists (Compound Fracture). — Under these conditions the diagnosis is com- paratively easy in the majority of cases by both inspection and palpa- tion at the seat of fracture if the patient is seen immediately after the injury. A fissured fracture can be recognized as a fine, hair- like opening, from which blood escapes (Figs. 6, 7, and 8). At times the edges may gape. The fissure can be followed in many cases until it disappears at the base of the skull. One can differentiate it from a suture by the fact that it is impossible to rub the blood away in the case of a fracture. The diagnosis is con- firmed in many cases by evidences of frac- ture of the base (see below), or by those of intracranial injury (see page 34)- A depressed frac- ture of the vertex can be readily diagnosed when the edges of the scalp wound are re- tracted. The depres- sion may be linear, 7'.^., there may be one or more large fragments which have slipped under and are firmly fixed beneath the ad- jacent skull, or the depression may be gutter-like or saucer-like, the center of the depression resembling the center of a star, from which the lines of fracture radiate (Fig. 14). The diagnosis of a punctured- fracture of the skull, such as follows a bayonet thrust, a bullet, or the use of some sharp projectile can be made — (a) from the history; (b) from the appearance of the scalp wound, and (c) from the examination of the skull itself. The question may arise. How deep does the fracture extend ? It may, in general, be said that : I. Fractures of the external table alone can be diagnosed positively Fig. 7. — Fracture of Frontal and Nasal Bones. 26 SURGICAL AFFECTIONS OF THE HEAD. as only involving this table, if the fragments are removed. Such a fracture may occur when the skull is struck obliquely by a sharp instru- ment, or in the mastoid or the frontal regions, where a considerable interval exists between the two tables. 2. Fractures of the internal table alone can be diagnosed only from the symptoms of the accompanying intracranial injury. 3. Fractures of both tables, of course, exist when there is a visible depression and after the majority of punctured or bullet wounds. Under the latter two of these conditions the internal table is more extensivelv involved. In a fissured fracture one can diamose a fracture Fig. 8. — Fracture of Occipital Bone Extending into the Posterior Fossa. of both tables if there is evidence of intracranial injury or if the fissure is enlarged by chiseling. This latter step is never justifiable for merely diagnostic reasons in the absence of serious symptoms. Diagnosis of Fracture of the Skull at a Later Period. — ^The question may arise months or perhaps years after an injur}^, when one of the late sequelce, such as Jacksonian epilepsy, insanity, etc., have developed, as to whether a fracture had ever occurred. In the absence of a history from a reliable source, we must depend upon our objective examination, which may show one or all of the following: I. Deformity in the shape of a depression of the vertex. All the conditions enumerated on page 23 must be excluded. FRACTURES OF THE SKULL. 27 2. Hyperesthesia of the scalp, which can be determined by repeated tests. 3. A painful scar. At times pressure upon such a cicatrix may cause an aura. 4. Persisting evidences of intracranial injury or of fracture of the base, such as nerve paralysis, etc. 5. The development of a traumatic cephalhydrocele in children is positive proof of a fracture having occurred (see page 19). IIL The Interpretation of Certain Special Signs of Fracture of THE Base. The diagnosis of a fracture of the base of the skull is made from one or more of the following signs : 1. Hemorrhages into or the presence of air in the tissues around the base. 2. Escape of blood, cerebrospinal fluid, or even brain substance externally from certain cavities, such as the ear, nose, and mouth, which communicate with the seat of fracture. 3. Evidence of injury of the cranial nerves or of the vessels at the base of the skuh. 1. Hemorrhages or the Presence of Air in the Tissues. — Ecchy- moses appearing in the eyelids, around the mastoid, or the nape of the neck are of value, if the blow has not been received over the region in which the subcutaneous hemorrhages have occurred, and especially if the latter begin to appear some hours after the injury, and increase in amount in the first few days. Orbital (subconjunctival) hemorrhages are quite frequently present, and, if excessive, an exophthalmos may be produced, which is almost positive evidence of a basal fracture. Escape of air into the subcutaneous tissues, producing emphysema or a crackling sensation of the skin upon palpation, only occurs after frac- tures comriiunicating with the mastoid cells or frontal sinuses, and, when found, is positive evidence of a fracture. 2. Escape of Blood, etc., from the Ear, Nose, and Mouth. — ^The escape of blood from the ear from other causes than a fracture of the base is of short duration and small in amount. Bleeding may occur from one ear alone, and this is very frequent, or it may take place from both. If it spurts, the internal carotid artery must have been torn. If it occurs in very large quantity without pulsation, a large sinus has been lacerated. Bleeding from the ear can be said to be clue to a basal fracture, if after cleansing the ear and wiping out the blood one ex- cludes the following sources of hemorrhage: Tearing of the cartilagi- 25 SURGICAL AFFECTIOXS OF THE HEAD. nous auditory canal in its anterior or posterior ^Yall, simple rupture of the membrana tympani, and flow of blood from wounds of the scalp or external ear into the canal. The first and last of these can be elim- inated by cleansing the ear and then observing the reaccumulation of blood. The rupture of the membrana t}mipani causes only a slight and transitory hemorrhage. Blood escaping from the nose or mouth is only of diagnostic value if one can exclude local injury, and if it persists for a number of hours. Very rarely one can obsen-e hemorrhage in the retropharj^gneal struc- tures or the escape of blood from the Eustachian tube, when the mem- brana tympani is not torn. The flow of cerebrospinal fluid most often occurs from the ear, and can be distinguished from blood-serum by the large quantity of fluid, the high percentage of sodium chlorid and the small percentage of albumin which it contains. Less frequently cerebrospinal fluid may escape from the mouth or nose. Several cases have been reported where a diagnosis of basal fracture has been confirmed by the flow of cerebrospinal fluid persisting for years after the injur}'' (rhinorrhea). The flow, whether from the nose, mouth, or ear, is increased by coughing or any form of exertion. The escape of brain tissue is rare, except in fractures involving the orbit or the temporal bone, and, when present, is absolute evidence of a fracture. One can then find ganglion- cells microscopically. 3. Injuries of the Nerves and Vessels at the Base. — lai Inju- ries of Nerves in Basal Fractures. — In the majority of fractures of the base, certain cranial nen-es are more frequently injured than others, owing to the fact that the majority of the fractures pass through the petrous portion of the temporal bone (Fig. 12), and from here forward; hence one should always examine a patient for evidences of paralysis of the seventh, sixth, third, and fourth ner\-es in the order named, and then the remaining nerves. At the same time one must not forget that injuries of all of these nen^es can occur without fracture of the base, so that a diagnosis of fracture should not be made from nerve paralysis alone, but by careful consideration of the other signs, as subcutaneous hemorrhages, flow of blood or cerebrospinal fluid from ears, nose, and mouth, with the evidences of nerve or ^'essel injury at the base. In addition to these three factors, in making a diagnosis a fourth is to be added, and that is whether the accompanying signs of injury to the brain fto be considered later) confirm the diagnosis already rendered probable by the other three. Injury of the Facial Nerve. — This shows itself as a peripheral FRACTURES OF THE SKULL. 29 paralysis affecting the ocular, labial, and nasal groups of muscles. When the case is first examined, this paralysis is best demonstrated by pressure upon the supraorbital nen^es, as shown in Fig. 9. This manipulation, unless the coma is extremely deep, causes such pain that the patient will contract the facial muscles of the non-paralyzed Fig. g. — Method of AL^king pKLbSUKE upon the Supraorbital Ner\-es. To be employed in the diagnosis of certain intracranial affections (see text). The examiner should stand be- hind the patient's head, and make pressure with the index-finger of each hand over the supraorbital notches. side. It is also of aid in distinguishing genuine from feigned uncon- sciousness or from an alcohohc stupor. The paralysis of the facial nerve is usually unilateral, and may in- volve other branches of the nerve beside those supplying the muscles of expression. The paralysis is rarely permanent. It, like evidences of injury to all the nerves at the base, may not appear at the time of the accident, but several days later, owing to a secondar}^ periostitis. 3° SURGICAL AFFECTIONS OF THE HEAD. Injuries of the Third, Fourth, and Sixth Nerves. — Injuries of the third cranial or motor oculi nerve cause external strabismus and ptosis. The pupil is widely dilated and does not react to either hght or accom- modation. There is also double vision. Injury of the fourth nerve causes diplopia. In attempts at downward convergent vision the in- ternal rotation of the eyeball fails to take place. Paralysis of the sixth nerve results in internal strabismus and marked diplopia. The injuries of all these nerves are usually unilateral, owing to their involvement in frac- tures involving the base close to the apex of the orbit. Injury of the Auditory Nerve. — ^According to some authors (Rawling), the seventh and eighth nen^es are more frequently injured than any others, but others (Graf and Brun), from the analysis of a large number of cases, state that the order given above, viz., seventh, third, fourth, and sixth, represents the greater frequency of in- . ^k . volvement. „^p\ """* .^^ The eighth nen-e is most wK iH^^^^^ frequently involved in fracture ■^ ''"^^^^^^^k of the base with the seventh, and upon this association rests much of the question as to whether the deafness resulted from the injury. If the audi- tory nerve is injured there is loss of hearing by bone con- duction and loss of hearing of the higher tones. Injuries of the Olfactory Nerve. — ^The effect of injury to this nerve is anosmia, or a loss of sense of smell on the side of injury. The presence of anosmia aids in locahzing the fracture in the anterior fossa (cribri- form plate of ethmoid). One must rule out hysteria, catarrhal nasal conditions, and fifth-nerve disturbances. Injury of the Optic Nerve. — ^A fracture of the base may be followed by choked disc, because the dural covering of the nerve is injured; this quickly subsides, but an optic atrophy may remain. Fig. 10. — Facial Paralysis of Peripheral Origin Following Gunshot Wound of Right Facial Nerve . Note the inability to contract the muscles of the eyelids and the muscles of expression of the face proper, resulting in obliteration of the nasolabial fold and droop- ing of the angle of the mouth. FEACTURES OF THE SKULL. 31 Injury 0} the Trigeminal Nerve. — This nerve is seldom involved in fractures of the base. There are both sensory and motor disturbances . The motor are loss of function of the masseter and pter}^goid muscles on the side of the injury, so that the patient is unable to keep the jaws tightly together. The loss of sensation involves almost the entire lateral half of the face, the conjunctiva, nasal and buccal mucous mem- branes, including the tongue, often causing a trophic ulcer of the cornea. Injury of the Ninth, Tenth, and Eleventh Nerves. — Comparatively few cases of injuries to these nerves have been reported follow- ing fracture of the base. The paralyses of all three of these nerv'es are often asso- ciated, on account of their close relation at the base. In four of the cases reported there was dysphagia from paralysis of the palatal muscles. There were also dis- turbances of speech and of voice, due to paralysis of the recur- rent larvTigeal. In three of live cases there was unilateral anes- thesia of the pharynx and lariTLx, and in two, disturbances of taste. In several cases in which there has been predominant involvement of the eleventh or spinal ■ accessory, it produces difficulty in raising of the arm, due to paralysis of the trapezius (Fig. 11). Injuries of the Twelfth or Hypoglossal Nerve. — This ncr\-e is also rarely involved, very few cases ha\'ing been reported. Its paralysis causes difficult deglutition, atrophy of the tongue, and speech is affected. Its injur}' is almost always in association with that of the ninth, tenth, and eleventh nerves. Fig. II. — Paralysis OF THE Right Tr.apezius Muscle, as a Re- sult OF Cutting the Spinal Accessory >s^erve During an Operation for Tubercular Glands of the Neck. P, Points to the paralyzed muscle. Observe the depression on the right side of the neck (paralyzed side). 32 SURGICAL AFEECTIOXS OF TPIE HEAD. (b) Injuries of the Vessels at the Base of the Skull in Fractures of the Same. — ^The diagnosis of these is considered on page 28. Special interest, however, is attached to cases of fractures of the base accom- panied by wounds of the internal carotid arter}' and cavernous sinus simultaneously, resulting in the formation of an arteriovenous aneu- rysm. This result of a fracture of the base can be diagnosed by the presence of a pulsating exophthalmos. There is marked protrusion of the eyeball; the upper eyelid is swollen and tense, and there is a dis- FiG. 12. — Most Frequkxt Lines of Fracture of Base of Skull. The black arrows indicate their direction if they traverse further than indicated in the illustration: i, Frac- ture of anterior fossa; 2, 3, fractures of middle fossa; 4. fracture of posterior fossa. tinct pulsation and thrill— the latter two, in cases where the common carotid is compressed. Pulsating exophthalmos may, however, fohow a fracture (gunshot wound of petrous portion of temporal) at another part of the skull, as reported by Barnard,^ and then be due to a sac- culated aneur}-sm of the internal carotid, without venous communi- cation. Diagnosis of Fracture of Individual Fossae of the Base. — In addition to being able to make a chagnosis of fracture of the ^ "Annals of Surgery," May, 1904. FEACTURES OF THE SKULL. 33 base, it may become necessary to ascertain through which fossae the fracture has occurred. The majority of fractures of the vertex due to a fall from a height or a blow upon the skull by some blunt instrument are followed by a fracture of the corresponding fossa of the base. In -S « •£ Anterior branch of middle meningeal artery Gasserian ganglion Posterior branch of middle meningeal arteri,' Superior petrosal sinus Olfactory nerve Optic nerve -( Internal carotid artery Facial nerve — Auditory nerve ■4 — - \"agus nerve "* Glossopharv'ngeal n. Spinal accessory n. Sigmoid sinus Hypoglossal nerve Lateral sinus Fig. 13. — View of Base of Skull, SnovfiNG Relation of Cranial Nerves, Carotid and Middle Meningeal Arteries, and Sinuses to the Foss^e. This illustration shows on the right side of the skull the most frequent lines of fracture at the base of the skull. many cases of fracture of the base following a punctured or gunshot wound the location of the wound of entrance is of assistance. The greater number of basal fracture Hncs pass through the petrous portion of one or both temporal bones, either as extensions or isolated fractures.^ Many fractures involve two or more fossas (Fig. 12). ^ Patel: " Revue de Chirurgie," April, 1903. 3 34 SURGICAL AFFECTIONS OF THE HEAD. Aside from these facts, the following table may be of aid (Fig. 13): [' I. Subconjunctival and subcutaneous (eyelids) hemor- rhages. . Exophthalmos (due to retrobulbar hemorrhage). Fractures of anterior fossae ■{ 3. Bleeding or escape of cerebrospinal fluid or brain substance from the nose or mouth. 4. Pulsating exophthalmos. I 5. Anosmia (due to olfactory nerve injury). f I. Subcutaneous hemorrhages around the mastoid. ! 2. Bleeding and escape of cerebrospinal fluid or brain I substance from the ear and mouth (per Eusta- Fractures of middle f ossffi ■{ chian tube) . 3. Signs of injury of second, third, fourth, fifth, sixth, and at times of seventh cranial nerves (see pages I 28, 29). f I. Subcutaneous hemorrhages at upper part of back of neck. Fractures of posterior fossae -j 2. Evidence of injury of seventh, eighth, ninth, tenth, eleventh, and twelfth nerves. [ 3. Bleeding from the ear. Albuminuria and glycosuria have been reported after basal fracture, but are of no diagnostic value. IV. Evidences of Intracranial Injury. In by far the greater number of cases a fracture of either the vertex or the base is accompanied by unconsciousness and other symptoms of intracranial injury. This is especially true of depressed fractures of the vertex, fissured fractures of the temporal region (middle menin- geal hemorrhage), and the majority of fractures of the base. The diagnosis of which particular form of injury to the intracranial structures has occurred depends, first, upon the length of time which has elapsed since the accident; and, second, upon a careful analysis of the symptoms. The length of time since the accident is of value because there is a certain sequence in which symptoms of the various conditions show themselves. 1. In the first forty-eight hours concussion, compression, and con- tusion^ symptoms appear. 2. After the first forty-eight hours symptoms of meningitis, cere- bral abscess, hernia cerebri, and pyemia from sinus thrombosis begin to appear. Quite rarely compression symptoms may show them- selves for the first time some days after an injury, a condition known as late traumatic apoplexy (page 53). ' The term contusion is synonymous with laceration of the brain or non-penetrat- ing wound. CONCUSSION OF THE BRAIN. 35 3. x\fter the immediate effects of injury have disappeared or im- proved, the so-called late sequelas, such as traumatic neuroses, epilepsy, and chronic traumatic abscess, may appear. In the majority of cases it is of the utmost importance, both as regards prognosis and treatment, to make a diagnosis as soon as possible after the accident. This can be done at times after the first examination of the injured person. In other cases a second or third analysis of the symptoms at intervals of a few hours will usually enable a diagnosis to be made, even where two or more of tliese intracranial conditions should chance to be present together. Concussion, compression, and contusion of the brain usually occur as comphcations of fractures either of the vertex or base, so that the symptoms of the latter lesions must be taken into consideration in the diagnosis of intracranial injuries. It must, however, not be forgotten that serious damage to the brain, intracranial blood-vessels, and nerves may also occur after mere contusions of the skull, after falls upon the feet or buttocks, or after blows or falls upon the chin or head without a fracture of the skull. CONCUSSION OF THE BRAIN. Concussion symptoms always appear immediately after the injury, but vary somewhat in their severity. They occur with especial fre- quency after fractures of the base. Graf found concussion symptoms in 76 of 90 cases of fracture of the base. There are three classes of cases: (a) mild; (h) moderately severe, and (c) severe. In those who recover from the immediate effects of the concussion of the brain there is an initial stage of depression, and a second stage of irritation or reaction. Mild Cases. 1. Unconscious for a few seconds to minutes, rarely half an hour. 2. Pulse but little affected. 3. Respirations a little slower than normal. 4. Skin pale and cold. 5. Vertigo, linnitus, or flashes of light. 6. No memory of events just before accident. STAGE OF DEPRESSION. Moderately Severe. 1. Unconscious for a num- ber of hours. 2. Pulse slo.w and small (between 40 and 60). 3. Respirations slow and shallow. 4. Skin pale, cold, and clammy. 5. Pupils contracted or di- lated equal, and re- spond to light. 6. No memory of events be- fore accident, when re- action sets in. Severe. 1. Unconscious for a short period, followed by death. 2. Pulse rapid and weak. 3. Respirations shallow and rapid. 4. Skin pale, cold, and clam- my. 5. Pupils same as in moder- ately severe. 36 SURGIC.AX AFFECTIONS OF THE HEAD. Stage of Deprjession. — {Continued.) iSIiLD Cases. Moderately Severe. Severe. 7. No rise in blood-pres- 7. Involuntarj^ micturition 7. Same as in moderately sure. and defecation. severe. 8. Vomiting — either during 8. Subnormal temperature. period of unconscious- ness or upon recover}^ from same. 9. Traces of sugar or albu- 9. Rise in blood-pressure in min or both in urine. early portion, but rapid fall as vasomotor and other centers in the medulla become para- lyzed. 10. Rise in blood-pressures immediately after trauma. SECOND OR STAGE OF IRRIT.\TION OR REACTION. 1. Pulse becomes stronger and more rapid, until normal. 2. Respirations deeper and more rapid, until normal. 3. Surface of skin becomes warmer and redder. 4. Temperature normal or slightly above. 5. Great mental irritability and apathy. 6. Same vomiting. The symptoms of concussion in the average case ynW. be considered below in differentiating it from compression and contusion (see page 54). COMPRESSION OF THE BRAIN. The symptoms of cerebral compression of traumatic origin vary both in their intensity and in the time of onset, according to the cause. I. Compression from sphntcrs of depressed fracture (Fig. 14). The S}Tnptoms appear almost immediately after the injury and are asso- ciated with those of concussion and contusion (see table on page 54). II. Compression from intracranial hemorrhage. This may arise — {a) from the middle meningeal arter}^ (extradural hematoma or extrameningeal hemorrhage) (Fig. 21). (b) From the pia araclmoid (subdural hematoma or intermeningeal hemorrhage). (c) From the vertebral arteries and intracranial portions of the internal carotids. {d) From the venous sinuses. Compression from any of these causes appears in one of four ways: I. First, symptoms of concussion, then a free intcr\-al followed by compression symptoms. COMPRESSION OF THE BRAIN. 37 2. Distinct interval after accident without aay symptoms of intra- cranial injur}^, then signs of compression begin to appear. 3. No perceptible interval between the symptoms of concussion and of compression, the symptoms of the concussion at first obscuring those of the compression. 4. Compression symptoms rarely appear a num- ber of days after the accident (late traumatic apo- plexy) . III. Compression symptoms from infection of the meninges or the brain, or from tumors of the brain. Signs of cerebral compression due to infection appear after the first forty-eight hours. Compression symptoms due to extradural hema- toma from a laceration of the middle meningeal artery appear early, and are quite marked within a few hours after their onset. Hemorrhage from injury of the vessels of the pia arachnoid or the sinuses cannot be distin- guished from middle meningeal hemorrhage in the majority of cases, but appears later, is less rapid, and the symptoms are not so marked (see pages 48, 49). The experimental work of Kocher^ and of Cushing^ on the subject of cerebral compression is being so rapidly confirmed by chnical observations, that the classification given by them will be followed here. According to these writers, there are four stages of compression of the brain. First, or State of Compensation. — ^There are practically no symptoms with the exception of severe headache, which maybe due to irritation of the dura. Second, or Stage of Incipient or Mild Com- pression. — ^The symptoms of this stage are due to an obstruction to the outflow of venous blood (dysdi- aemy rrhosis) . They are : (a) Headache — location varies according to seal of lesion. (b) DeHrium, great irritability, and restlessness. ^ Nothnagel's " Specielle Pathologic," Bd. ix, 3. ^ "American Journal Medical Sciences," June, 1903. Fig. 14. — Fracture of Skull with De- pressed Fragments (Scudder). Compression of brain by bone. Fig. 15. — Fracture of Skull with Mid- dle Meningeal Hemorrhage (Scud- der). Compression of brain by blood. 3° SURGICAL AFFECTIONS OF THE HEAD. (c) Dullness of perception. (d) Pupils contracted or unequal. Mslv have conjugate deviation of eyeball. (e) Choked disc. (f) Pulse slower than normal (50 to 70). Tension moderately increased. (g) Respiration slower but regular. (h) Temperature higher than normal (101° to 103°). The greater the degree of compression, the higher the temperature. (j) Rise of blood-pressure. This can be determined by the use of the Riva-Rocci apparatus fFig. 16). Fig. 16. RiVA-RoCCI SPHYGMOMAXOiCETER AS MODIFIED BY CoOK. In cases of compression of the second stage (incipient or mild compression), there will be moderate increase of blood-pressure to 180 to 190 mm. of Hg. If this does not rise, it indicates that the intra- cerebral tension has not increased. Concussion will cause a rise in blood-pressure immediately after the accident, but it decreases as the symptoms subside. In cases where moderate compression exists, in addition to the concussion,' the blood-pressure either remains stationar\' or there is a hght rise, due to a posttraumatic cerebral edema fCannon- BullardM. Third, or Stage of Advanced Compression. — In this stage the compression is so great as to cause an anemia of the brain both of ^ "Boston Medical and Surgical Journal," August, 1901. COMPRESSION OF THE BRAIN. 39 the cortex and medulla (adiajmyrrhosis). The vasomotor center is stimulated and causes such a rise in blood-pressure that it compensates for the increased intracranial tension. The diagnosis of this stage of compression may be made from the following (see footnote^) symptoms: (a) The patient is deeply stuporous and gradually becomes coma- tose. (b) The pupil is dilated and not responsive on the side of the lesion. There may be conjugate deviation of the eyeballs toward the side of the lesion. (c) Marked choked disc. (d) Pulse very slow. May drop to 40 or 50 and is of high tension. (e) Respirations much slower and stertorous. They may be Cheque-Stokes in character. (/) Temperature higher than normal. It rises as compression increases. (g) Blood-pressure greatly increased. In case the hemorrhage (if this be the cause of the compression) is subdural (intermeningeal), the increase is slow^ and only moderate; if, however, there is a large extradural clot or a large fragment of depressed bone, the rise will be rapid and quite marked, falhng soon after the pressure is reheved, or if this does not occur, the fourth or stage of paralysis sets in, with its marked fall of blood-pressure. Following the primary fall after the operation there may be a second rise, due to a variable degree of cerebral edema. (h) Focal symptoms. These may or may not be present, according to whether the pressure is or is not exerted over a localized area. If present, there may be hemiplegia of the face, arm, and leg of the opposite side, or a monoplegia of the arm or leg, at times accompanied by twitch- ings or convulsions of the affected muscles. There is also increase of the deep or tendon reflexes, with loss of control of the bladder and rectum. Fourth, or Stage of Paralysis. — In this stage the intracranial tension can no longer be compensated for by increased blood-pressure, and there is inhibition of the functions of the medulla through extreme anemia. The symptoms are us'ually preceded by those of the third, or stage of advanced compression. In this fourth or paralytic stage the diagnosis may be made from the following: (a) Deep coma. The patient cannot be aroused. (b) The pupils are dilated and not responsive. ^ The symptoms of this stage should be compared with those of the stage of incipient or mild compression. 40 SURGICAL AFPECTIONS OF THE HEAD. (c) The pulse is rapid and weak, corresponding to the fall in blood- pressure. (d) The respirations are shallow and irregular. Frequently they are of , the Cheyne-Stokes' type. (e) Rapid fall in blood-pressure. Many patients are seen under one of the following conditions, when the differential diagnosis must be made between coma due to cerebral compression and that due to other causes: 1. A comatose middle-aged man or woman is brought to the hospital with the history of having fallen on the street and sustained a scalp wound an hour or less before admission. 2. Same condition and history as above, but smell of alcohol in breath very marked. 3. Man apparently deeply unconscious, with no external wound or signs of injury, but with a history of having fallen, six or eight hours before examination. One must distinguish the symptoms of cerebral compression under any or all of the above conditions from the following forms of feigned or genuine coma: (a) Coma due to ordinary cerebral apoplexy. (b) Uremic coma. (c) Diabetic coma. (d) Alcohohsm. (e) Opium poisoning. (/) Hysterical coma (or often malingering). The diagnosis which is the most difficult is in the class of cases mentioned under 3, where the patient has, for example, been placed in the cell of a police station over night, with the diagnosis of alcoholism made by the police officers. Here the fall was originally due to the alcohol, but resulted in a skull fracture with hemorrhage, and the free interval between concussion and compression either did not exist or was overlooked. This instance is especially referred to on account of the fallacious teaching that symptoms of compression are always preceded by a free interval, which latter is diagnostic of this condition. Every case of coma must be systematically examined before a diagnosis is made. The average duration of life in non-operated cases of middle meningeal hemorrhage is 25 hours (Brun), and this fact emphasizes the impor- tance of an early diagnosis of cerebral compression of traumatic origin. The differential diagnosis of the various forms of intracranial injury will be taken up at the end of this section. As can be seen from the accompanying table, it will not be difficult to make a diagnosis of the o o < 2; K5 I i+H [/I r H Id •'-' O rt bO oj O tn o ;g "^ iH • tn o S -" "-I '-^ "- O rt -^ S'> c o o .Sid <" & "^ u cd 3 ni _C f> O (U ?t3 H ^ w 2; kS 2 S '^ g o ^ f U5 3 TJ u ^ ^ O -rf 3 •r-. bO s s 0.::i, go' « .^ p c/1 n3 I- o D-o' h rt o .S-S o.d. ^ fc O a-i=i ^-'d O u_ r ° c U-^ O -tJ c in 1 s i tn i U. . " d tj , r >- t" CO 1) 4) .. d T3.0 1^ Lymph-node Involvment. None. \ a 1) d d 6 d 0' d 6 d d Rate of Growth. Slow, rarely- rapid. 1 2 Oh _0 bjo Zn CO .00 1 CO 1 CO :2 :2 CI, d P^ ■ i t/2 13 a 13 S bD It 13 6 S do ,7 M ^ d Cl. -d en CO w h w a Wo C i 6 d 13 1 d . ai • d d d Most Frequent Location. More frequent in lower jaw. i) 1=1 1 1 ■ ■ C ^ cs ^ ^ .t; u u ,^ f§ ^3 jpJl ^H ,g C pq > d t3 <; t3 C CI -| • Its 1 d i nj vO H C3 4) ^ V tn 3 1- C 1 Q g £ s ! tn 1 ^ !u S P d 1 S 2 -S s u -§ £ C u I-. a ; CO P 5 '0 u no SURGICAL AFIECTIOXS OF THE HEAD. the consistency of the normal tooth. Both forms occur during the eruption of the permanent teeth, especially the third molar or wisdom teeth. The softer varieties may resemble a sarcoma but are much slower in growth and cause no pain. The harder forms are always found at the neck of the tooth and are irregular in outhne. Cystadenomata. — This form of new growth is analogous in structure to the multilocular cysts of the ovary. They arise from the epithelium- containing odontoblasts which cover the root of the tooth. This epithehum proliferates and forms a gland-hke structure whose lumen dilates until a cyst is formed. These tumors occur between the ages of sixteen and thirty-five, especially in women. They are more fre- quent in the lower jaw than in the upper, in the proportion of one to thirty. Their growth may be quite rapid and they cause parchment-like crepitation, also called egg-shell crackhng, as they develop. They can be recognized by their rapid and massive growth, the parchment-Hke crackhng, and the absence of tendency to ulceration or of enlargement of lymph-nodes. They must be differentiated from dentigerous cysts, which are usually monocular and occur at an earher age. The jaw also does not attain the size of cystadenomata. The same is true for the softer odontomata, the harder form not being difficult to differentiate. Sarcomata occur at a younger age, do not grow as rapidly, and, unless of the softer variety, are more bone-like. Carcinoma rarely occurs in the lower jaw and appears later in life than either cystadenomata, odontomata, or dentigerous cysts. Osteomata. — Osteomata occur most frequently in the lower jaw, although occasionally an osteoma will develop into the antrum of High- more and give rise to symptoms of pressure upon the infraorbital nen'e and gradual bulging of the anterior wall. They may grow also toward the orbital cavity or toward the nose. Both in the upper and lower jaws they can be recognized by their bony consistency and their slow growth. Occasionally osteomata having their origin in the wall of the antrum may be recognized by the .v-ray, but othenvise the same may be said of this class of tumors as of all the tumors of the upper jaw which originate in the antrum, that they cannot be diagnosed until they grow beyond the walls and cause bulging of the same. One can, however, suspect their presence from the complaint of dull pain over the antrum and, in the case of sarcomata or carcinomata, of escape of blood and mucus from the nose, without the ordinar}' symptoms of an empyema. Osteomata of the lower jaw must be differentiated from ostcosarcomata. If TUMORS. Ill periosteal, they can be readily recognized, sometimes growing to quite enormous size. Their growth, however, is exceedingly slow, and, even though they be central in origin, they rarely cause any atrophy of the overlying bone such as will give rise to egg-shell crackling. Granulomata (granulation-tissue tumors). — ^These are soft masses of granulation-tissue which project beyond the level of the gum from the sockets in which carious teeth He. They are oftenest found in children. The absence of an increase in size, their soft consistency, and their relation to a carious tooth will enable a differentiation from a fibroma or a true epuhs to be made. Fig. 67. — Osteoma. (International Text-Book of Surgery.) Fibromata. — ^These may either have their origin in the periosteum or in the central portions of the jaw. The former are more frequent, only eleven cases having been reported of the latter. Both the central and periosteal forms occur between the ages of sixteen and thirty-five. The periosteal can be recognized clinically as a small, hard tumor, growing from the periosteum of the outer surface of the jaw, usually of the lower jaw. The central form cannot be recognized until it has grown to a sufficient size to have caused expansion of the bone overlying it. They occur almost exclusively in the lower jaw, and until there is a prominence over the bone (Fig. 68) the patient is not aware of its 112 SURGICAL AFFECTIONS OF THE HEAD. presence unless exceptionally it presses upon the mental nerve. Parch- ment-like crackling, so frequently observed in the other forms of tumors Fig. 68. — View or Lower Jaw in a Case of Central Fibroma. \ .r^ of the jaw, is very rarely present, only once in eleven cases. As a rule, the cortex of the bone is intact. The chief conditions from which these tumors must be differentiated are in a periosteal fibromata, from a periosteal sarcomata. The consis- tency of the latter is softer, as a rule, and the growth is more rapid than in the case of a fibroma. The central fibromata, after they have caused sufficient expansion of the bone to be recognized, must be differentiated from the central form of sarcomata. As a rule, central fibromata do not grow as rapidly as the same form of sarcomata, nor do they give rise to Fig. 69.— Epulis (Edmund Owen). egg-shcll Crackling SCnsatioUS, Or break through the shell of bone in their growth, as do the sarcomata. The periosteal form is also called false or fibrous epuhs. TUMORS. "3 There is a rare form of central actinomycosis which may resemble the central fibromata, but in these there is tendency to early softening and perforation of the bone with sinus formation, and the discharge of pus containing yellowish granules with the characteristic organisms. Chondromata. — Chondromata seldom occur in the jaws as pure cartilage tumors. They are most frequently present in the form of chondrosarcomata or osteochondromata, which are allied to the sar- comata clinically. They occur as central chondromata in both the upper and lower jaws and as periosteal chondromata in both jaws, but especially in the upper. They form hard nodular tumors, which have the characteristic consistency of cartilage. The sensation on palpation can be com- pared to that felt on pressure over the nasal cartilages. Their growth varies greatly, that of the pure chondromata being very slow, so that the central form cannot be recog- nized until it breaks through the bone. The more they re- semble the sarcomata in his- ologic structure, the more rapidly do they grow. Malignant Tumors of the Jaws. Sarcomata. — Sarcoma is the most frequent form of malignant tumor of the jaws. They may arise from the gums at the side of the tooth, giving rise to a soft, often pedunculated (Fig. 69) tumor, which must be dif- ferentiated from the ordinary fibrous form of epulis. In the case of the sarcomatous epulis, there is chnically the history of a rather rapid growth and expansion of the surrounding bone. Histologically, these tumors show distinctly the structures of a mixed giant- and spindle-celled sarcoma. The fibrous form of epulis is much firmer than the sarcomatous in consistency, and its growth is much slower. There is also but little tendency to cause expansion of the bone. Another variety of tumor must sometimes be differentiated. This is not a true tumor, but simply a mass of granulation-tissue which may arise in the Fig. 70. — Sarcoma or the Antrum. (International Text- Book of Surgery.) 114 SURGICAL AFFECTIONS OF THE HEAD. cavity from which either a tooth has been extracted or in which a carious tooth Ues. It is composed of flabby, edematous granulations, and has a narrow pedicle, which can be traced up into the cavity occupied by the extracted or carious tooth. It is much softer than the sarcomatous epulis and can be readily recognized as composed of granulation-tissue. It can be differentiated from the sarcomatous epulis by the fact that the latter is firmer than this granuloma. Both the granuloma and sarcomatous epulis bleed easily. The history will also show that the sarcomatous epulis has growTi more rapidly than the granulation-tissue tumor, spreading over several alveoh, and not being confined to a single alveolus, as is the case in a granuloma. The central sarcomata be- gin either in the body of the lower jaw or in the bone sur- rounding the antrum of High- more in the upper jaw. The diagnosis of such a sarcoma of the upper jaw of the endosteal or myelogenous type can only be made, as a rule, when the growth has caused expansion of the over- lying bone. If the tendency of the growth is toward the nose, it has at times been treated for a polyp. Usually it grows toward the face, causes a prominence of the cheek, pushes the eyeball up, and, if toward the palate, causes a bulging in the latter (Fig. 70). In the lower jaw these endosteal or central sarcomata cannot be recognized until the bone has been expanded by the growing tumor (Fig. 71). All types of sarcomata may occur, but most frequently one finds the osteosarcomata (Fig! 72). The diagnosis of these forms of central sarcomata of the lower jaw may be made by the history of a rapid enlargement and the local exami- nation. In the latter one finds an enlargement of the jaw, which is usually marked both on the side toward the mouth and that toward the cheek. In the softer varieties there is distinct egg-shell crackhng. In Fig. 71. — Typical Enlargement of the Face Due TO TtJMOR OF THE LOWER JaW (SaRCOMA) , EITHER OF THE Ramus or of the Body, Close to the Junction of these Two Portions of the Infe- rior Maxilla. TUMORS. Ii: the harder forms, with more analogy to the osteosarcomata, the growth is quite firm and bone-Hke. In the upper jaw, sarcomata must be diiJerentiated from carcinomata arising from the antrum of Highmore. This cannot be done until the tumor has gro^^^l to a sufficient size to be palpated through the mouth. In the case of osteosarcomata or chondrosarcomata, palpation shows them to be much firmer than a carcinoma. Carcinomata tend to ulcer- ate upon breaking through the walls of the antrum much earher than is the case with sarcomata. In regard to age, carcino- mata appear at a much later period of Hfe than sarcomata. There is quite early involve- ment of the regional lymph- nodes (submaxillary and deep cervical) in a carcinoma. Carcinoma of the upper jaw, as a rule, grows much more rapidly, and is more painful than is the case in sarcomata of the upper jaw. From fibromata, both of the upper and lower jaw, sar- comata may be differentiated by their more rapid growth and the tendency to invade surrounding structures. The central fibromata of the lower jaw are quite localized, often encysted tumors, which is not the case with sarcomata. From the other forms of benign tumors of the jaws, like chondroma and osteoma, sar- comata may be readily differentiated by their rapid growth. It must be remembered that the pure form of chondroma is comparati^•cly rare, the majority of these being chondrosarcomata. Carcinoma of the Jaws. — ^These appear (a) either as primary tumors of the gums or growths arising from the mucosa of the antrum of Highmore, or (b) as secondary tumors by direct extension from neighboring carcinomatous involvement, cither of the mouth or of the face (Fig. 73). The diagnosis of carcinoma arising from the mucous Fig. 72. — Recurrent Osteosarcoma of the Superior Maxilla. This illustration shows the typical site of tumors of the upper jaw which protrude externally, showing how they involve the surrounding osseous and soft structures. The curved line indicates incision of first operation. ii6 SURGICAL AFFECTIONS OF THE HEAD. Fig. 73. — Primary Carcinoma of Gums of Lower Jaw, Well Shown by Everting Lower Lip. membrane^of the antrum can only be made, as was stated above, when the tumor is of sufficient size to grow toward the nose, face, or palate. They usually appear dur- ing the later years of life; their growth is quite rapid, much more so than is the case of sarcoma of the upper jaw, and there is greater tendency to ulcera- tion. The most frequent form of carcinoma, how- ever, is that which arises from the mucous mem- brane of the gums (Fig. 73) or palate, and of this variety those occurring in the upper jaw are more frequent. They ahnost invariably appear in elderly people in the form of a carcinomatous ulcer which is deeply excavated and has raised, everted, and markedly indurated edges. There is quite early enlargement of the submental, submaxillary, and deep cervical lymph-nodes (Fig. 74). The diagnosis in the earher stages is not diffi- cult when one considers that all other forms of ulceration which occur at this period of Hfe are not accompanied by enlarged indurated lymph- nodes. Such ulcerations may occur in elderly people as the result of sharp teeth or of an ulcerative stomatitis, as the re- sult of improper care of the mouth. In both of these the ulcers are quite superficial; Fig. 74. -enormous Secondary Carcinomatous ^ _ Lymph-nodes of Neck, Following Primary Car- the edges are seldom indur- cinoma of gums, shown in fig. 73- INFECTIONS OF THE JAWS. II7 ated, and the ulceration rapidly disappears as soon as the cause is removed. From tertiary gummata the carcinomatous ulcer can be differen- tiated by the fact that gummata seldom occur on the jaws except on the palate. There is usually a history of syphihs or the presence of syphilis elsewhere. No enlargement of the regional lymph-nodes occurs and the edges are never as indurated as is the case in a carcinomatous ulcer. The administration of potassium iodid will show a marked improve- ment if the ulcer is a gumma. INFECTIONS OF THE JAWS. In order to be able to recognize inflammatory processes of the jaws, it is necessary to have a clear conception of their pathology as well as of their clinical appearance. It is important to determine (a) the nature of the process and (b) the extent of involvement of the bone. The nature of the affection varies somewhat according to the cause. The most important of the latter are: 1. Infection from the teeth. 2. Infection following compound fractures. 3. Tuberculosis. 4. Syphihs. 5. Actinomycosis. 6. Phosphorus necrosis. 7. Acute pyogenic osteomyelitis. The extent of the process varies according to the cause. In the majority of cases following tooth infection there is a suppurative per- iostitis with the formation of subperiosteal abscesses and resultant necrosis of the underlying bone. Such an abscess may form around the root of the tooth (Fig. 75) and remain confined to this location or it may extend to the extra-alveolar portion of the bone. Here its further course varies. In the upper jaw the pus may (a) burrow toward the antrum of Highmore (Fig. 75), or (b) penetrate the tissues of the cheek and perforate externally, or (c) it forms a subperiosteal abscess which causes a swelling at the line of reflection of the gum and mucosa of the cheek. In the lower jaw the anatomic conditions differ. Here infective processes either form (a) an abscess within the alveolus itself around the root of the tooth, or (b) it causes a marked periostitis, usually on the outer aspect, or (c) the infection progresses to the floor of the mouth SURGICAL AFFECTIONS OF THE HEAD. and to the loose cellular tissue of the neck (Fig. 75) and, if not arrested, to the anterior mediastinum. These various degrees of infection may result in necrosis of the bony structure of a single alveolus or of a number of them. In the lower jaw the above referred to periostitis of the outer aspect is either of a plastic nature w^hich undergoes resolution or the infection causes a subperiosteal abscess with necrosis of a la- mella or more of the cortex of the bone. A true osteomyel- itis, /. e., an involve- ment of the medulla of the bone, is very rare after tooth infection. In compound frac- tures, tuberculosis, syphilis, actinomyco- sis, and in infection following the acute ex- anthematous diseases the pathologic changes differ only in extent from those already de- scribed. The chief diagnos- tic points of the var- ious inflammatory pro- cesses are as follows: Infection from Teeth. — Abscesses around the root of the teeth cause severe pain referred to the tooth, accompanied by tenderness on pressure, redness, and swelling of the gum. There is always more or less swelling and induration of the overlying skin, especially in the upper jaw, often causing marked edema of the lower eyelid and upper Hp. If the infection migrates through the root canal it may penetrate the alveolus and give rise to an abscess be- neath the gum (gum-boil), indicated by swelHng and fluctuation here. If the underlying bone of the alve®lar process is necrotic, the opening Fig. 75. — Sagittal Section of Head to Show Spread of Sup- puration FROM Infected Teeth; and also Location of Retro- pharyngeal Abscesses. SA , Subperiosteal abscess of upper jaw opening toward cheek and mouth in direction of black and white arrows, respectively; lA, sub- periostea! abscess of lower jaw opening toward submaxillary region and chin in direction of white and black arrows, respectively; LA , infec- tion in submaxillary subcutaneous tissue as a result of abscesses arising from teeth and from floor of mouth (this condition is also called angina Ludovici) ; EA , infection around roots of bicuspid and molar teeth spreading toward antrum in direction of arrow; SA, retro- pharyngeal abscesses. INFECTIONS OF THE JAWS. 119 from which the pus escaped either spontaneously or by incision con- tinues to discharge. A fine probe passed through the opening encounters denuded dead bone. If the necrosis invoh^s a number of adjacent alveolar processes there is more or less retraction of the gums, with con- stant discharge of pus. Upon inserting a probe the extent of the necrosis can be readily determined. In advanced cases the entire alveolus may be necrotic. The recognition of a form of infection which occurs with especial frequency in the lower jaw is the palpation of a swelling which is usually quite hard at first over the infected tooth. The further clinical history is Hke that described above. In children spontaneous perfora- tion through the cheek over both upper and lower jaws is frequent. A sinus is present externally along which a probe can be passed until exposed bone is encountered (Fig. 75). In connection with the diag- nosis of infection of the upper jaw from carious teeth it is well to call attention to the fact that an em- pyema of the antrum of Highmore, especially if acute, will cause irrita- tion of the nerves of the bicuspids and first molar, so that these teeth are often thought to be dis- eased. Infection Following Com- pound Fractures. — ^Necrosis of the jaw is present in these cases when (a) a sinus is present, either within the mouth or externally, which leads to denuded bone at the seat of fracture; (b) if abscesses form after a fracture which heal and then fill up again until a piece of necrotic bone is either removed by operation or spontaneously dis- charged. Tuberculosis of the jaws is quite rare. It is most frequently located at the junction of the superior maxilla and malar bone. It causes a sweUing along the lower border of the orbit which has all of the clinical characters of a tuberculous or cold abscess. These are the gradual appearance of a swelhng without pain, redness, or rise of local Fig. 76. — Suppuration of the Submaxillary Lymph-nodes. Infection of the surrounding cellular tissue of this region and of the cheek, the latter almost clos- ing the eye, followed tooth infection. I20 SURGICAL AFFECTIONS OF THE HEAD. or general temperature. The skin over it is bluish and, after evacuation J of the pus has occurred, a sinus persists whose edges are hned by flabby, often caseous, granulations. Tuberculosis also occurs in the alveolar and palatal processes and in the body of the lower jaw. The diagnosis in these locations can only be made by excluding the other forms of infection and the peculiarly slow onset. Tuberculosis of the lower jaw may resemble sarcoma, syphilis, and actinomycosis. A sarcoma of the body of the lower jaw grows more rapidly; it is not accompanied by necrosis of the bone, but a gradual thinning of the same (page 114). Syphihs is rare in the lower jaw and there are usually evidences of the disease elsewhere. Actinomycosis is not apt to be accompanied by swelhng of the lymph-nodes, as is the case in tuberculosis. The pus contains fine yellow granules in which the ray fungus is found. Syphilis. — In the lower jaw it appears as a periostitis which causes either circumscribed or more diffuse swellings. The diagnosis can only be made if other causes of periostitis, especially those due to tooth infection, are ex:cluded. There is usually, however, a history of syphilis elsewhere. The hard palate is the most frequent locahzation of tertiary syphilis in the jaws. It causes a painless swelling which opens spontaneously, exposing denuded, often foul-smelling, bone. In other cases the patient may present himself for an opinion as to the nature of a perforation of the hard palate leading into the nose. The alveolar processes of both jaws and of the nasal process of the upper jaw are also frequent seats of syphihs, especially of the type known as the late hereditary, which first appears in children at the age of puberty. A diagnosis of the latter form can be made by a careful history, the absence of any other causes of necrosis, and antisyphihtic treatment. Actinomycosis. — ^This inflammatory disease of the lower jaw occurs far more frequently than was formerly thought. It is almost invariably secondary to a primary infection of the gums or mucous membrane of the cheeks, which is rapidly followed by infection of the soft tissues of the face and neck, as described on page 118. In the jaws actinomycosis may either appear as an accompaniment of the same affection in the soft parts or as an independent clinical entity. There are two forms, a peripheral and a central, both of which most frequently involve the lower jaw. The peripheral form of jaw actino- INFECTIONS OF THE JAWS. 121 mycosis either causes a superficial necrosis or abscesses, varying in size from a pea to a hazelnut, filled with soft granulations. In the pus from these latter cavities the actinomyces are found. These abscesses may first arouse the suspicion of the surgeon or dentist on account of the absence of acute inflammatory symptoms and the fact that they recur from time to time. The central variety of actinomycosis of the lower jaw occurs in two forms — (a) a penetrating and (b) a tumor-Hke form. In the former there is marked rarefaction without the formation of sequestra, but considerable thickening of the outer layer of bone. This form is very virulent, especially when it affects the upper jaw. The tumor- like form is rarely met with in man, occurring usually in cattle as lumpy jaw. Its course is very slow and results in the formation of multiple cysts. The diagnosis of actinomycosis of the jaws, as is the case elsewhere, can only be made if the characteristic organism is found. It bears great resemblance clinically to ordinary tooth infections, especially if associated with involvement of the cellular tissue of the neck. The course of actinomycosis is slower, it is more often accompanied by trismus (see page 122), and there is often a history of chewing hay, grain, etc., or of having been around infected cattle. Phosphorus Necrosis. — Owing to the regulation of the manufac- ture of matches, this disease is practically extinct. It affects the lower jaw more often than the upper. The chnical picture is that of a suppu- rative periostitis, but the pus is very foul and necrosis is more extensive than is the case in ordinary tooth infection. Acute Suppurative or Pyogenic Osteomyelitis. — ^This affection usually occurs in young persons, in the lower jaw. It may follow the acute exanthemata like measles, scarlatina, and variola, or occur simultaneously with acute osteomyeHtis of other long bones. In other cases the-re is no apparent cause. The diagnosis presents no difficulties. In the milder type the disease more frequently involves the upper jaw. There is gradually swelhng of the face over the superior maxilla of one side or over the entire lower jaw with moderate fever. This is followed by necrosis of the entire alveolar process with the loss of the temporary teeth as well as the non-erupted permanent teeth. In the more severe form the course is much more like that of the same disease in the extremities. It begins with a chill, followed by high fever and marked increase of pulse-rate. There is extensive swelhng and redness of the soft parts over the jaw and severe septic symptoms. 122 SURGICAL AFFECTIONS OF THE HEAD. DISEASES OF THE TEMPORO-MAXILLARY JOINT. This articulation is subject to the same forms of inflammation as is the case in the joints of the extremities. These are: Primary Acute Arthritis: 1. Acute traumatic arthritis (sprains). 2. Acute articular rheumatism. Secondary Acute Arthritis: 1. Metastatic, .(a) Through infection with ordinar}^ pus cocci by metastasis from foci elsewhere in the body. {h) Through infection with gonococci, after scarlatina, typhoid, etc. 2. Direct Through extension into the joint from neighboring foci of suppuration. Chronic Arthritis: 1. Tuberculosis. 2. Arthritis deformans. Of the above, the acute inflammations are most often a result of acute articular rheumatism or a metastasis from a gonorrheal infection. The diagnosis is not difficult. There are redness, swelhng, and pain over the joint, which latter is just in front of the tragus of the ear. Pyemic inflammation is also not rare. The chronic forms are characterized by pain over the joint upon movements of the jaw, crepi- tation, and slight swelhng. There are two forms of chronic inflammation of the joint which lead to relaxation of the ligaments and favor subluxa- tion. One of these forms is the result of an arthritis deformans which usually accompanies the same disease in other joints. The move- ments of the jaw are accompanied by pain and crepitation and are very difficult. Ankylosis of the Temporo-maxillary Joint. — Trismus (lockjaw) is the name given to inability to open the mouth. It may be congenital and acquired. The following forms exist of the latter: (a) A reflex spasm of the masseter muscles following acute inflammatory diseases of the jaws and occurring most frequently during the eruption of the wisdom-teeth — it has been given the name '"symptomatic lockjaw"; (h) as the first symptom of tetanus (see page 540); (c) as a result of acute or chronic disease of the temporo-maxillar\' joint; {d) as a result of cicatrices in the tissues around the joint; (e) as a result of disease of the adjacent bones, especially after osteomyelitis of the condyle of the STOMATITIS. 123 lower jaw in children. It is very apt to follow acute gonorrheal arthri- tis and those varieties of suppurative arthritis which are due to metastasis or to direct extension from neighboring foci in the ear, mastoid, etc. The diagnosis of the existence of an ankylosis is much easier than that of its cause. The cause of an acquired ankylosis can be ascertained through a careful history, an examination of the rest of the body and of the structures around the joint. A congenital ankylosis is frequently accompanied, or rather followed, by a lack of development of the lower jaw.^ Diseases of the Mouth. Injuries. — -Injuries of the lips and buccal cavity present no diffi- culties in diagnosis. It is of interest to note that wounds of the mouth are covered with a grayish-white deposit within twenty-four hours, which to those unaccustomed to see it causes them to think it at first sight to be the pseudo-membrane of diphtheria. STOMATITIS. There are two principal forms of inflammation of the buccal mucosa, viz., an ulcerative or catarrhal and gangrenous. In gangrenous stoma- titis or noma there is a history of some recent infectious disease, such as measles, or the patient is quite cachectic. In its earhest stages there is a blister, usually on the inner side of the cheek, which soon becomes gangrenous. The area begins to spread along the mucosa and in the depth of the cheek, so that it penetrates the cheek. The gangrene is accompanied by a markedly fetid breath and the symptoms of general sepsis. Ulcerative stomatitis is characterized by greatly swollen, reddened, readily bleeding gums, accompanied by salivation. Particles of food and detritus collect at the junction of the gums and teeth, and there is great fetor. Ulcers often appear on the inner side of the lips and cheeks and along the borders of the tongue. They are flat and could only be confused with mucous patches of secondary syphilis. The latter are, however, not accompanied by fetor, swollen bleeding gums, and sali- vation unless there is an accompanying mercurial stomatitis. Even then the distinction can be made by an examination of the remainder of the body for other evidences of syphihs, and the fact that the mucous patches are seldom ulcerated, are fewer in number, and seldom occur on the gums or inner side of the cheeks, but most often on the edges of the tongue. ' Orlow: "Deutsche Zeitschrift fiir Chirurgie," Bd. 60. 124 SURGICAL AFFECTIONS OF THE HEAD. In scurvy the gums are swollen and bleed readily, and there are apt to be subperiosteal hemorrhages causing tenderness over the long bones and hemorrhages into the joints causing swelling of the latter. SYPHILIS. Tertiary syphihs in the form of ulcerating gummata occasionally affects the inner side of the cheek and may cause perforation. The favorite seat of perforations, however, is at the junction of the hard and soft palates, where it causes deep ulceration and perforation of the palate. Tertiary syphilis can be distinguished from car- cinoma by the absence of enlarged lymph-nodes and the lack of induration in syphilis and the pres- ence of evidences of the dis- ease in its tertiary form else- where. Fig. 77- -LocATiON OF Various Cysts in Relation to Tongue and Floor of Mouth. R, Ranula; Deep D. or Thy. C. or L. G., location of deep dermoids, of thyroglossal cysts and of lingual goiter at base of tongue; Sup. D., location of superficial dermoids at floor of mouth causing bulging of submental region; T, dorsum of tongue; Hy, hyoid bone; E epiglottis. THE DIAGNOSIS OF CONDI- TIONS AT THE FLOOR OF THE MOUTH. A differential diagnosis must at times be made of conditions which occur at the floor of the mouth. These are (Fig. 77): 1. Inflammatory conditions: (a) Angina Ludovici. (b) Salivary calculus. (c) Acute ranula. 2. Tumors: (a) Of the submaxillary sahvary gland. (b) Chronic ranula. (c) Dermoids. (d) Thyroglossal cysts. (e) Carcinoma of the floor of the mouth. (/) Lipoma. Angina Ludovici. — ^This occurs either as a compHcation of scar- THE DIAGNOSIS OF CONDITIONS AT THE FLOOR OF THE MOUTH. 1 25 latina or of a tooth or tongue infection. It causes a tense brawny infiltration of the floor of the mouth, pushing the tongue upward and causing difficuky in swallowing, in speech, and in breathing. It is accompanied by the evidences of severe systemic infection (fever, leukocytosis, etc.) and the skin of the neck soon becomes infiltrated and of a dark red hue. Salivary Calculus. — ^This may occur without inflammatory reac- tion or ulceration and is easy to feel when the finger "IIB is pressed along the floor of the mouth or a probe is passed along Wharton's duct. If the calculus be sur- rounded by connective tis- sue, it may be quite hard and resemble a carcinoma, especially if the tissues around the calculus be ul- cerated and the ulcer be sur- rounded by exuberent gran- ulations. A differential diagnosis can usually be made by the use of a probe passed through the buccal opening of Wharton's duct, on either side of the frenum of the tongue close to the floor of the mouth, and en- countering the calculus. Acute Ranula. — ^The patient gives the character- istic history of recurrent swellings which appear very suddenly, especially while eating.- The swelling is usually most marked just below the angle of the jaw and pushes up the floor of the mouth. It may attain the size of a fist and subside as rapidly as it appeared. It is due to the occlusion of Wharton's or the sublingual ducts, so that the saliva collects within the glands. The history is sufficiently typical to make a diagnosis even during the interval. Solid Tumors of the Submaxillary Salivary Gland. — ^These are either chondromata or cndothcliomata. They protrude below the jaw Fig. 78. — Ranula. Note the prominent tumor on right side of floor of the mouth, pushing the tongue upward. 126 SURGICAL AFFECTIONS OF THE HEAD. (Fig. 1 1 6) and bulge in the floor of the mouth. A diagnosis can be readily made by the firm consistency of the tumor and the fact that its major portion Hes in the normal position of the submaxillary sahvary gland on the inner side of the jaw, close to the angle. Chronic or Ordinary Ranula. — As a rule, this tumor is unilateral (Fig. 78). It pushes the tongue upward and appears as a translucent tumor varying in size from a pea to an egg in the floor of the mouth. It has its origin in the cystic dilatation of the subKngual gland and is a retention-cyst. Its fluid contents are like the white of an egg. It can be differentiated from a hpoma of the floor of the mouth by the yellowish color, the lobulated structure, and firmer consistency of the lipoma. From a dermoid of the sublingual variety (Fig. 77) it can be distin- guished by the fact that a dermoid is doughy, is not translucent, has thicker walls, is attached to the lower jaw or hyoid, and Hes deeper. A cystic dilatation of Wharton's duct or chronic ranula causes a cylin- dric translucent swelling and is accompanied by some enlargement of the submaxillary sahvary gland. Dermoid Cysts. — ^These occur at the floor of the mouth and have as their chief characteristic a doughy consistency, so that they pit on pres- sure. They are of a yellowish color, are softer than a calculus, and occur between the fifteenth and twenty-fifth year. They are situated deeper than a ranula (Fig. 77) and cause more bulging of the submental region. Thyroglossal Cysts. — ^These are softer than dermoid cysts and push the tongue up and back, causing difficulty in speech, in swallowing, and in breathing. They appear externally between the hyoid and the lower jaw in the median line. Their deeper situation, absence of translucency, and the fact that they occur in the median line serves to distinguish them from a ranula. Carcinoma of the Floor of the Mouth.— This condition may occur as a primary one and be situated in a fold of mucous membrane, so that attention is only called to its presence by pain. Upon lifting the tongue up, or pushing it to one side,, one can detect an ulceration with dirty floor and indurated base and edges. The only condition hkely to be confounded with it is a gumma. In the latter there are no enlarged submental or submaxillary lymph-nodes, the induration is less marked, and there is either the history of or presence of syphihs elsewhere. Carcinoma of the floor of the mouth due to extension from the tongue or gums presents no diagnostic difficulties. Lipoma at the floor of the mouth is very rare. THE TONGUE. I 27 TUMORS OF THE INSIDE OF THE CHEEKS. The most frequent forms of neoplasms in this situation are the vascular tumors and carcinoma. The former have been referred to previously (see page 98) as invading at times the entire thickness of the cheek, so that they present the typical picture on the inner side. An angioma may be primary in the buccal cavity, i. e., on the inner side of the cheek, on the tongue or fauces. The hemangiomata are usually of the venous type, so that one can see the typical soft bluish swelling disappear on pressure. The lymphangiomata, if present, form a large, soft tumor of the entire cheek, congenital in origin, and growing at times to an enormous size. Carcinoma of the inner side of the cheek is usually an extension from the jaws or hps. Only twelve cases of primary carcinoma of the cheek have been recorded. They occur close to the lower jaw and may penetrate the cheek. Their induration, raised, everted, hard edges, and tendency to early ulceration, with enlargement of the regional lymph-nodes, are so characteristic that the diagnosis is not difficult. TUMORS OF THE PALATE. The majority of these, if primary, are fibromata, and can be readily diagnosed from their position and consistency. They usually arise laterally and grow toward the median line. They are covered by periosteum and are slow in growth. They cause difficulty in swallowing and speech and must be distinguished from tumors of the upper jaw and from naso-pharyngeal polyps, which have grown toward the antrum. In the case of tumors of the jaw we have usually to deal with mahgnant growths which increase in size rapidly and also cause bulging of the anterior surface of the superior maxilla. In the case of naso-pharyn- geal polyps an examination of the naso-pharynx will show the origin of the primary tumor. In addition, by palpation one can feel that there is a connection between the palatal vault and the pharyngeal tumor (Fig. 79). THE TONGUE. Congenital Affections. — The most important congenital affection is the ordinary tongue-tie, which is due to an abnormal shortness of the frenum linguee. This can be recognized in infancy by inability to pro- trude the tongue as far forward as normal. The organ can seldom be 128 SURGICAL AFFECTIONS OF THE HEAD. protruded further than the teeth. The condition may interfere with nursing and later with speech. The tongue is bound doAMi to the floor of the mouth and the shortened frenum can be easily demonstrated by lifting the tongue up with a grooved director. Injuries of the Tongue. — ^The most frequent injuries of the tongue are punctured or lacerated wounds. These are either due to foreign bodies, which penetrate the tongue during eating, or the wounds are received during a fah, the tongue being caught between the upper and lower teeth. At times the wounds are so extensive as to almost com- pletely sever the tip of the tongue. Foreign bodies may be re- tained in the tongue and cause a circum- scribed abscess, which can be recognized by a swelling which is usu- ally unilateral, by ten- derness, and by a sense of fluctuation. Dental or Decu- bital Ulcers, — ^These may follow the con- stant irritation of a sharp tooth and cause severe pain. Such den- tal ulcers are usually situated opposite the canine teeth, at the edges of the tongue, and cause consider- able pain. The diag- nosis can be made by finding the source of irritation and the fact that the ulcer heals rapidly when its cause is corrected. The differentiation of these decubital ulcers of the tongue from carcinomatous and syphihtic ulcers will be referred to again (see page 135). Acute Parenchymatous Glossitis.— This may follow wounds of the tongue or may occur as a comphcation of the acute infectious diseases. This condition occasionally results in an abscess of the tongue or may be the starting-point of an infection of the cellular tissue of the floor of the mouth and neck called angina Ludovici. Fig. 79. — Various Locations of Pharyngeal and Esophageal Tumors. U, Upper jaw, L, lower jaw, Hy, hyoid bone; E, epiglottis; i, naso-pharyngeal growths; the arrows point in the direction of their most frequent extension toward the nose and pterygo-maxillary fossa and downward toward the mouth; 2, location of retropharjTigeal growths; 3, location of carcinomata at the junction of anterior wall of pharynx and beginning of esophagus. THE TONGUE, 129 Acute glossitis can be recognized by the enormous swelling of the tongue, which causes obstruction to breathing, with resultant dyspnea. The tongue cannot be moved, feels very firm and board-Hke, and there is profuse saHvation and severe pain. The temperature as a rule is not high. Swallowing and the taking of nourishment is greatly interfered with. The mouth is usually held open and the entire clinical picture is that of great anxiety. On account of the inabihty to move the tongue there is also great danger of aspiration pneumonia. This condition of acute glossitis lasts from three to five days and may be complicated by an acute edema of the glottis. This complication can be diagnosed by the marked increase in dysp- nea, cyanosis, and the stridor accompanying the inspiratory efforts. The only condition with which acute glossitis can be confused is an acute edema of the floor of the mouth due to inflammation around a sali- vary calculus. This latter con- dition is more localized and seldom extends to the tongue. It is always present on the floor of the mouth and by palpation one can usually demonstrate the presence of the calculus lying in Wharton's duct. Leukoma (leukoplakia , chronic glossitis or psoriasis linguae). — This is a condition which is very frequent in smokers and is present on the inner side of the cheeks and hps, as wefl as upon the tongue. On the latter it pre- sents itself in the form of milk-white patches of varying size. These patches of leukoplakia are distinctly white in color, especially on the dorsum (Fig. 80). On the edges and under surface of the tongue they have a httle more bluish tint and are translucent. The disease may be so extensive as to cover the entire dorsum of the tongue. The chief condition from which it must be differentiated is the 9 Fig. 80. — Psoriasis Lingu.i; (Hutchinson). Notice the silvery-white area characteristic of this disease. 130 SURGICAL AFFECTIOXS OF THE HEAD. mucous patch occurring in secondan,' syphilis. The mucous patch is of a pure white or yellowish- white color and more opaque than the leukom- atous or smokers' patches. There is a greater tendency on the part of the mucous patches to extend and there is usually evidence of syphihs elsewhere, such as a secondary eruption on the body or mucous patches at the angle of the mouth or on the tonsils. Whitish patches not infre- quently appear on the edges of the tongue in patients who have had syphihs, which cannot be differentiated from ordinan,^ , leukoplakia, except from the histon," of a previous syphihs and their greater tendency to ulcerate. Secondary mucous patches are most often found on the edge of the tongue, while leukoplakia appears usually on the dorsum of the tongue. In leukoplakia there is no enlargement of the submaxillar}^ lymph-nodes, whereas the mucous patches are often accompanied by this condition. Tuberculosis of the Tongue. — This is usually present as a condi- tion secondary to tuberculosis of the lar}-nx, tonsils or lungs, and is oftenest found near the tip of the tongue. The ulcer is of a grayish-pink color, the floor is covered with a caseous material, and the edges are undermined and not indurated. Tubercular ulcers are usually quite painful. They can be differ- entiated from syphiHtic ulcers by the fact that the latter have indurated edges and there is considerable induration of the tissues around them. The ulceration is deeper and the edges are not undermined. There are no enlarged lymph-nodes and there is usually the presence or the history of syphihs elsewhere. Syphihs affects the middle, while tuberculosis is more often found on the lateral portions of the tongue. SyphiHtic ulcers 'are painless. Tuberculosis of the tongue can be differentiated from carcinoma of the tongue of the ulcerative type by the facts (a) that the induration in carcinoma is verj^ marked; (b) that the ulcer itself is not painful in the early stages; (c) that there are no evidences of tuberculosis in the lungs or elsewhere, and (d) the carcinomatous condition is accompanied by early enlargement of the submaxillary or deep cervical lymph-nodes. The age also will assist in the diagnosis, carcinoma occurring as a general rule at a later age than the average case of tuberculosis. Syphilis of the Tongue. — This may appear (a) in the form of a primary chancre; (b) in the form of secondar}' mucous patches, which may or may not have broken down to form ulcers; (c) in the form of gummata, which may be superficial or deep, and (d) as a syphilitic atrophy of the base of the tongue. Chancre of the tongue is a comparatively rare lesion. It is usually THE TONGUE. 131 present on the upper surface or anterior edge. It shows a sHght central depression, with its floor covered with necrotic tissue, and has moder- ately indurated edges. There is usually quite early enlargement of the submaxillary lymph-nodes (Fig. 81). The diagnosis can be confirmed within a comparatively brief period by the appearance of secondary symptoms. The principal condition which must be differentiated from a primary syphihtic lesion of the tongue is a decubital or dental ulcer, which may also be present along the edges of the tongue. This dental ulcer is not accompanied by any enlargement of the lymph-nodes, and one can usually find the source of the ulcer in the form of a sharp tooth and the ulcer heals as quickly as the source of irritation is removed. Secondary syphil- itic lesions or mucous patches occur on the borders under surface of the tongue. They may occur simply as pure white, small, slightly raised areas, which are quite opaque, or as minute ulcers. They are usu- ally quite painful and often fissured. A con- dition from which they must be differentiated is the small, painful, so-called aphtha some- times associated with disturbances of digestion. These aphthous patches are usually oval in outline, seldom multiple, as is the case with mucous patches, and much more painful. The absence of the history of syphilis and of evidences of the disease elsewhere, as well as the fact that the condition heals within a few days after regulation of the diet, will serve to exclude this condition. Tertiary Syphilitic Lesions 0} the Tongue. — These occur about five to fifteen years after the primary infection and are usually multiple. They may occur as gummatous infiltrations seated deeply in the substance of the tongue, which ulcerate later, or as superficial gummata. They are Fig. 81. — Chancre of Left Edge of Tongue, with Secondary Enlargement of Submaxillary Lymph-nodes, to which THE White Arrow Points. 132 SURGICAL AFFECTIONS OF THE HEAD. Fig. 82. — CAKCiNOiiA of Meddle of Left Edge of Tongue Developing upon a GuiiMA. Anterior vievi. most frequently pres- ent on the dorsum of the tongue, but may also develop, rarely, along the edge of the tongue. An ulcer, due to a broken-down gumma, has only a moderate amount of induration. The edges are not much above the level of the sur- rounding tissue and the floor of the ulcer is necrotic. The edges are not everted, Kke those of an epitheh- oma, and are quite steep or straight. There is no enlarge- m.ent of the regional lymph-nodes, viz., the submental, submaxillary, and deep cervical. The differentiation from a dental or de- cubital ulcer can be readily made by ascer- taining the source of irritation and by the fact that the indura- tion in decubital ulcer is seldom as well marked as in either a syphihtic or a carcin- omatous ulcer. In case of any doubt, the removal of the cause of the irrita- tion and the adminis- tration of iodid of po- tassium for a period of one week will clear up the diagnosis. Fig. 83. — Lateral View of a Carcinoma of the Left Edge of THE Tongue. Same patient as shown in Fig. 82. NOX-MALIGNANT TUMORS OF THE TONGUE. 1 33 In addition to this therapeutic test, one can usually obtain a history of or evidences of syphihs elsewhere. TertisLTy syphihs may occur in the form of fissures at the edges of the tongue, which are quite painful, and can only be discovered by separating the furred epithehum of the tongue. Syphihs is the most frequent cause of fissures of the tongue. In advanced cases these fissures may be long and sinuous and resemble either a tubercular or carcinomatous ulcer. A carcinoma appearing in the form of a fissure has markedly indurated edges and there is always accompanying en- largement of the submaxillary and deep cendcal lymph-nodes. Car- cinoma may, however, develop upon a tertiary syphihtic lesion (Figs. 82 and 83) and under these circumstances a differentiation between the two at an early stage can only be made by considering the degree of induration, w^hich is far greater in carcinoma than in syphihs, and finding enlarged, hard hmiph-nodes under the chin and at the angle of the jaw. The fourth form of syphihs of the tongue is the so-called syphihtic atrophy, which was first described by Virchow. This is always at the base of the tongue and shows itself by a smooth, shining condition, due to a loss of the epithehum of this portion of the tongue. It may appear and disappear during the course of syphihs from time to time or may persist. It may be necessary in some cases to differentiate the deep form of gummata from neoplasms of the tongue, such as carcinoma or sarcoma. Both of these are much firmer and more sharply demarcated from the surrounding structures of the tongue, the gumma is inelastic, and cannot be separated from the surrounding structures. The gum- mata often occur multiple, while carcinoma and benign tumors are almost always single. The differentiation of tertiary syphihtic lesions from carcinoma will be referred to later. NON-MALIGNANT TUMORS OF THE TONGUE. These arc lipoma, hemangioma, lymphangioma, and papilloma. The lipoma occurs late in hfe, near the tip or on the dorsum of the tongue. It is very slow in growth, and can readily be recognized by the fact that the mucosa is stretched over the tumor, and through it one can see the lemon-yellow fat. There is also distinct lobulation. Hemangiomata may occur in the capillary form as deep red nodules, the size of a pea, either single or multiple, on the dorsum or edges of the tongue. They present the same characteristics as this 134 SURGICAL AFFECTIOXS OF THE HEAD. form of tumor elsewhere, namely, that the tumor itself can be caused to disappear by pressure but speedily returns as soon as it is relieved. The other form of hemangioma, which occurs on the tongue, is the soft palate and cheek. It may involve only a small area, or an entire half of the tongue, causing considerable swelKng, which can be greatly decreased by pressure but rapidly refills. Lymphangioma. — Lymphangioma may occur in the capillar}^ or cavernous fonns (Figs. 84 and 85). The former can be recognized by the minute vesicles or rarely larger cysts which are present along the edges and dorsum of the tongue. The vesicles are translucent and about the size of a millet seed. The cavernous form causes a condition knowTi as macroglossia. It is usually congenital, or develops in early infancy (Fig. 84), and is not infrequently accompanied by the capillary form. It may cause such an enlargement of the tongue that it cannot be withdrawn into the mouth but constantly protrudes through the Kps. It causes disturbances in the development of the Hps, jaws, and teeth through pressure. One of the characteristics of this form of new growths is the fact that it is subject to recurrent attacks of inflammation, which are accompanied by great swelHng and pain in the affected portion. If the condition is circumscribed it may resemble a sarcoma of the tongue, but can be readily differentiated from it by the histon,- of its having been present since birth and the fact that its growth is far slower than that of a sarcoma. Papilloma of the tongue occurs in the form of soft, pedunculated tumors which can be readilv diagnosed. MALIGNANT TUMORS OF THE TONGUE. Sarcoma. — Sarcoma of the tongue is quite rare. It has only been found in young girls and women. It grows rapidly and ulcerates at quite an early stage. It must be differentiated from gumma and from carcinoma of the tongue. This can be done by remembering the fact that gumma is usually multiple, even though it be present in the form of a nodular growth within the substance of the tongue. Gummata occur at a later period of Hfe and there is usually a history of syphiHs or the evidences of the disease elsewhere. The growth is far less rapid than is that of a sarcoma. From carcinoma a sarcoma of the tongue can be differentiated by the fact that the induration is much harder in a carcinoma than in sar- coma and that the former appears at a later period in hfe. Carcinoma of the Tongue. — This may appear in one of four forms: o ■-I > 2; ^ o > CL S > ^ & p" 2; a PC Q < ^, n > U2 p] H M w P ^^ w ^ ■^ H >^ G 1:3 r Cfi g 'H- ^ t~> > CA .w Wo "■ Y' H t/3 p 3' ni 2; > •-< crq ,_, d •Z > "O ■-1 p bd ET ' ' t-' p" CO ►< K p" ►T3 ^ t-+i oq n !? > G ff- 3 <^ 2 00 rc rti w Cn a D *TIU S > -13^ z £■ c <^ ^ rt t/i' W ^^ P H C K oq Si? c rc a- MALIGNANT TUMORS OF THE TONGUE. 135 (a) As a fissure, with indurated edges; (b) as a carcinomatous ulcer; (c) as a warty growth whose base has become indurated, and (d) as a hard nodule in the substance of the tongue. Usually one does not see carcinoma in the nodular form. Ordi- . narily it appears as an ulcer or fissure. According to Butlin, the most important precancerous condition is the papilloma, which precedes the development of carcinoma. The warts enlarge in size, the base becomes harder, and sooner or later ulcer- ation occurs. Not infre- quently the warts are present (Fig. 86) upon a tongue which is the seat of an extensive leukoplakia. The least frequent form of carcinoma of the tongue is the nodule in its substance. It must be differentiated from sarcoma or gumma in the sub- stance of the tongue before it begins to ulcerate. This has been referred to above, under the head of sarcoma of the tongue. The characteristics of car- cinoma of the tongue, after ulceration has once begun, are: (a) It appears most fre- quently along the edges or under surface of the tongue, (b) there is early enlargement of the submaxillary and deep cervical lymph-nodes; (c) the edges of the ulcer are everted and very firm, and (d) the floor of the ulcer is covered with a large amount of necrotic epithehum. There is usually severe pain, which radiates to the car. In the later stages the carcinomatous ulcer has a very fetid odor, is very painful, and severe hemorrhages may occur. Carcinoma of the tongue must be differentiated from the following conditions: (a) Dental or Decubital Ulcers. — These arc present along the edges Fig. 86. — Papillary Form of Carcinoma of Tongue De- veloping ON Psoriasis Lingd.s (Jonathan Hutchinson). 136 SURGICAL AFFECTIONS OF THE HEAD. of the tongue opposite a sharp tooth. The ulcer is never as deep as that of a carcinoma, nor are the edges as indurated, and there is no enlargement of lymph-nodes. The ulcer heals in a few days if the tooth is either extracted or the sharp edge filed down. (b) From Tubercular Ulcers. — These never show the Induration which characterizes the carcinomatous ulcer. The tubercular ulcer is quite shallow, usually with undermined, not raised, edges, and there is no lymph-node enlargement. They occur at an earlier age and are usually secondary to tuberculosis of the larynx or lungs. (c) From syphilis the question of differentiation most often arises in the case of gummatous ulcers. The diagnosis, as will be seen in Figs. 82 and 83, is at times exceedingly difficult. In the case shown in the illustrations, the patient gave a distinct history of syphiHs and had well- marked symptoms of tabes dorsalis. The first diagnosis made in the case was that of epithelioma of the tongue, on account of the marked induration, and raised, everted edges, and deep ulceration. The administration of iodid of potassium caused a marked improvement in the condition, the induration and ulceration disappearing to a great extent. In a short time, however, these signs recurred, in spite of the continued administration of the drug. At the time the diagnosis of epithehoma was first made, there was an accompanying enlargement of the submaxillary lymph-nodes on the side upon which the ulcer was situated, and this was thought to confirm the diagnosis of epithehoma. The final diagnosis made in this case, after removal of the tongue, was that it had been a carcinoma of the tongue, which had developed upon a tertiary, i. e., gummatous ulcer. This case illustrates the difficulties of diagnosis between epithehoma and tertiary syphilis. According to Jonathan Hutchinson,^ at least 30 per cent, of the patients with epithelioma give the history of pre- vious syphihs. An accurate diagnosis can be made in the majority of cases, but in some only the microscopic examination decides. A therapeutic test may at times be fallacious, either from the fact that carcinoma may improve after the hygiene of the mouth has been attended to, or that, as in the case illustrated in Fig. 82, the carcinoma has developed upon a gummatous ulcer. In general, the following may be taken as the chief differential points, between epithehomatous and gummatous ulcers: ' " Practitioner," May, 1903. MALIGNANT TUMORS OF THE TONGUE. 137 Gummatous Ulcer. 1. Appears usually multiple on dorsum. 2. May occur at any age. 2, 3. But little if any enlargement of lymph- 3. nodes. 4. But little pain. 4 5. Induration less marked than in car- 5 cinoma. 6. lodid of potassium causes marked 6 improvement within a week. 7. Evidence of tertiary disease elsewhere. 7 Carcinomatous Ulcer. 1. Appears on sides of tongue and floor of mouth. 2. May occur as early as thirty. 3. Early and indurated enlargement of submaxillary and deep cervical lymph-nodes. 4. Considerable pain, radiating to ear. 5. Very marked induration. Edges raised and everted. 6. No improvement or only slight, unless carcinoma has developed upon a gummatous ulcer. No evidence of tertiary disease, unless carcinoma has developed in an indi- vidual with previous syphilis. Carcinoma of the floor of the mouth may spread to the under sur- face of the tongue, so that it is at times difficult to ascertain where the disease began. There is only one condition which it may at times be necessary to differentiate, under these circumstances, and that is the ulceration due to the infection of the tissues around a salivary calculus. There is not infrequently considerable painful induration around such a calculus, with ulcer formation, the ulcer being covered with foul granulations. It can be differentiated from a true carcinoma by the fact (a) that the induration is never as marked as in carcinoma; (b) by the use of a probe one can find the calculus, and (c) as a rule there is no induration of the lymph-nodes. It is aknost impossible to make a diagnosis between an unbroken gumma and the nodular form of car- cinoma, which occurs in the substance of the tongue, except perhaps the fact that the nodular form of carcinoma is single, while the gumma is multiple. There are other signs of syphihs or the history of syphihs in the case of a gumma. The only other conditions of the tongue which need to be mentioned are lingual goiter and lingual tonsils. Lingual goiter (Fig. 77) is an enlargement of the upper end of the original thyroglossal duct, which has its termination close to the foramen cecum at the posterior portion of the dorsum of the tongue. Ordinarily a lingual goiter causes no symptoms, except that when it begins to grow it may cause some difficulty in swallowing. It may be as large as a walnut and yet cause no inconvenience. The first symptom is generally an uncomfortable feeling at the base of the tongue, a fullness in the throat accompanied by a frequent desire to swallow. There is a change in the voice, which becomes thicker 138 SURGICAL AFFECTIONS OF THE HEAD. and nasal in quality/ There may be fits of coughing. Only in the case of the largest tumors is the respiration interfered with. Later in the disease there are recurrent, profuse hemorrhages. These occur at any time, without any apparent cause, the patient being simply aware that the mouth is filled with fluid, which on expectoration proves to be blood. The presence of the growth can only be determined by the use of the lar}Tigoscope or the finger. The tumor is soft, reddish in color, shows no ulceration or induration, or enlarged l}Tnph-nodes. The diagnosis can be made from the facts (a) that it is soft, not indurated or ulcerated; (b) it is not accompanied by enlarged l^Tnph- nodes, and (c) its course is a verv' chronic one. The cases so far reported appear to have occurred exclusively in women between the ages of fifteen and forty. The differential diagnosis of a hngual goiter includes : (a) Dermoid cysts. This is the only condition which offers any difficulty. It is generally yellow, grows rapidly, pits on pressure and is not vascular. (b) Angioma is a quite common tumor at the base of the tongue and may give rise to hemorrhages. It is, however, easily reduced by pressure, refilling immediately, and is of a bluish color. The Lingual Tonsil. — The enlargements of this group of adenoid tissue on the dorsum of the tongue, near the foramen cecum, may cause some symptoms, especially if they become inflamed or enlarged. These are pain in swallowing, aching, irritable throat, and coughing. The diagnosis can only be made by the use of the lar}Tigoscopic mirror. One then sees whitish folHcles, swollen and filled with secretion, extending in either direction from the foramen cecum. At times one of these may suppurate and be accompanied by parenchymatous glossitis. Affections of the Salivary Glands. Injuries. — Wounds of the submaxillary and subhngual glands are so rare that only those of the parotid will be referred to. Injuries of the parotid gland itself not infrequently occur in connec- tion with those of the face. Wounds of the gland parenchyma itself are of but little consequence, since a sahvar}' fistula rarely follows such an injury. Chief interest lies in injuries of the vessels passing through the gland and of the facial nerve, which divides within the capsule. The vessels which pass through ^Storrs: "Annals of Surgery," 1904. AFFECTIONS OF THE SALIVARY GLANDS. 139 the gland and might be injured by a penetrating wound are the temporo- maxillary (posterior facial) vein and the termination of the external carotid artery. The recognition of their injury does not differ from that of similar structures elsewhere. An injury of the facial tierve during its passage through the parotid capsule is recognized by the paralysis of the muscles of expression (Fig. 87). The naso-labial fold upon the side of the injury is flattened, there is inability to close the eyelids and to show the teeth or to whistle. Injuries of the parotid duct are more important than those of the gland itself. It may be wounded while (a) it is still in the parotid cap- sule, (b) during its pas- sage across the mas- seter muscle, and (c) while penetrating the tissues of the cheek to open into the mouth. The recognition of such injury is usually not difficult. Saliva is seen to escape from a wound in the cheek, especially during mas- tication. The diag- nosis is confirmed by inserting a fine probe through the opening of Steno's duct where it opens into the mouth opposite the second upper molar tooth. The probe will pass through the opening in the duct and emerge in the cheek wound externally. One can also observe the escape of colored liquids such as methylene-blue when injected into the buccal orifice of Steno's duct. A salivary fistula is rarely congenital. In the majority of cases it follows an injury to the gland or its duct or it is the result of abscess formation in the gland or in the duct with subsequent ulceration of the overlying tissues. In both cases there is an external opening, either over the glands or along the course of the duct, lined by granulations from which a watery fluid escapes. The secretion of a duct fistula is much greater than that of a glan- FiG. 87. — Left-sided Facial Paralysis. Involving all three groups of muscles supplied by the seventh cranial nerve, namely, the eye, nasal and labial groups. Note the obliteration of the naso-labial fold on the side of paralysis, the droop- ing of the left angle of the mouth, the inabihty to close the left eye- lid, and loss of action of the muscles of the eyebrows. I40 SURGICAL AFFECTIONS OF THE HEAD. dular one. In the duct fistulae there is an absence of any ejection of saliva from the opening of the duct within the mouth. This is best seen when the cheek is retracted while the opening of the duct into the mouth is observed. Salivary Calculi. — The majority of these occur in the excretory duct (Wharton's) of the submaxillary gland. They are very rare in Steno's duct. The calculi are usually the size of a pea or bean but occasionally attain to that of a pigeon's or hen's egg. Salivary calculi may give rise to the following clinical pictures: 1. They may remain dormant for many years and not give rise to any symptoms. 2. They give rise to acute attacks of salivary retention. These are recognized by the sudden appearance, usually after eating, of pain along the duct, accompanied by a markedly tender enlargement over the normal situation of the gland whose duct is blocked. After a few hours there is a sudden discharge of saliva into the mouth, and the swelling and tenderness rapidly disappear. With such a history of recurrent swelling one must always pass a probe into the duct or palpate along its course for the calculus, which can usually be readily felt. 3. There may be inflammation of the tissues around the stone and resultant abscess formation. This clinical form is characterized by the appearance of great pain, tenderness, and induration along the course of one of the salivary ducts. In the case of Wharton's duct this is most marked along the floor of the mouth, while in that of Steno's duct it is best felt with the iinger while palpating the inside of the cheek or externally along the course of the duct. In the latter location, i. e., Steno's duct, the first sign may be the appearance of an induration in the middle of the cheek, accompanied by redness and swelling of the skin lying over it. The diagnosis can be made from the location of the abscess and the absence of any other cause. 4. A salivary calculus may appear as an ulceration on the floor of the mouth or on the inside of the cheek. The ulcer has indurated edges and a dirty foul-smelling base. Its resemblance to carcinoma has already been referred to. The diagnosis can only be made by the use of the probe or the finger, which encounter the calculus lying at the bottom of the crater-like ulcer. ' Inflammatory Affections. — These may be acute and chronic. The acute may occur (a) as an epidemic variety of acute inflamma- tion of the parotid or submaxillary glands commonly called "mumps," This is fully described in the text-books on internal medicine and pre- sents but Httle difficulty in diagnosis. If, however, a complication AFFECTIONS OF THE SALIVARY GLANDS. I4I such as orchitis or oophoritis occurs, it is of great diagnostic importance to obtain the history of a preceding acute swelling in front of the ears or below the jaw, which lasted for a week to ten days. (b) The other form of acute inflammation of the sahvary glands occurs as a complication of typhoid and other of the acute infections diseases. It may also occur after laparotomies and is then given the special name of "coeliac parotitis." These so-called acute secondary inflammations almost always in- volve the parotid gland. The diagnosis can be made from the appear- ance of severe pain at first referred to the angle of the lower jaw and later in front of the ear and greatly increased by movements of the jaw. The onset of swelhng is rapid and there is marked edema and redness of the overlying skin. If suppuration occurs the skin-infiltration and redness increase and there is soon distinct fluctuation. The abscess may burst externally either through the external auditory canal or the cheek. Such a parotid suppuration may be the starting-point of a retropharyngeal and periesophageal phlegmon or the infection may spread to the skull and give rise to a fatal meningitis. Tuberculosis of the Salivary Glands. — This is a very rare affection, especially as a primary disease. It is not infrequent as the result of an extension of a tuberculosis of the lymph-nodes contained within the parotid capsule. In either form there is moderate enlargement of the gland and fistulse form, fined by flabby, often caseous, granulations. Syphilis. — This form of chronic inflammatory enlargement usually occurs in the tertiary stage. The disease almost always involves the parotid, causing a soft tumor-hke swelhng. The diagnosis of its syphilitic nature can only be made from the histor}^ and its rapid disappearance under appropriate treatment. Tumors of the Salivary Glands. — In attempting to make a diag- nosis of the nature of an enlargement of one of the sahvary glands one must bear in mind the following possibihties : 1. If the onset is sudden the enlargement is either of an acute inflammator}' nature or is due to an acute retention of secretion through obstruction of the excretor}' duct. 2. If the onset has been slow'and the increase in size gradual it may be due (a) to a retention-cyst, (b) to chronic inflammatory changes as a result of syphilis or tuberculosis, or (c) to a neoplasm. Retention-cysts and neoplasms occur far more frequently in the parotid than in cither the submaxillary or sublingual glands. Reteniion-cysts differ from the condition described on page 125 as acute dilatation of the ducts or glands themselves due to transitory ob- 142 SURGICAL AFFECTIONS OF THE HEAD. struction to the flow of saliva. Retention-cysts are permanent and are due to a complete and chronic obstruction of the duct. The accu- mulation of secretion may take place either in the duct or in the gland. In the former case (cysts of the salivary ducts) the condition must be thought of when an elongated sausage-shaped fluctuating tumor is found in a location corresponding to that of either Steno's or Wharton's duct. The swelhng is quite sharply demarcated and is not tender. Infec- tion of the contents may occur with all the signs of inflammation, e. g., pain, redness, etc. If such infection occur the swelling may resemble, in Steno's duct, an inflamed lymph-node in the cheek. This, however, is a very rare condition and can be readily excluded by its more super- ficial location and the absence of a primary focus. Cysts of the salivary glands give rise to a visible and palpable en- largement of the gland involved, especially if the cyst is situated close to the surface. They are very rare in the parotid and submaxillary, but occur more often in the sublingual gland. In the latter the condi- tion is known as ranula (see Fig. 78) and can be recognized by the location at the floor of the mouth, and by its fluctuation and trans- lucency. Tumors of the Salivary Glands. In the diagnosis of a tumor of the saHvary glands one must consider (a) the size of the growth; (b) the condition of its surface, whether smooth or nodulated; (c) its consistency, whether fibrous, cartilaginous soft, or cystic; (d) its clinical history, whether it remained stationary for many years and then suddenly increased in size, whether its growth has been rapid from the time it was first noticed or whether it has remained of about the same size for a considerable period. Tumors of the salivary glands are best divided into the following groups : ( (a) Fibromata. 1. Those of the benign connective-tissue type -< (b) Angiomata. t (c) Lipomata. 2. Mixed tumors (including sarcomata). 3. Carcinomata. I. Benign Connective-tissue Type: (a) Fibromata. — These are very rare. They are firm, encapsulated growths which run a benign clinical course. They grow very slowly and do not tend to recur when removed. (b) Angiomata. — These are also very rare and usually occur in chil- AFi'ECTIONS OF THE SALIVARY GLANDS. I43 dren. They greatly resemble simple hypertrophy and form irregular soft tumors. (c) Lipomata. — But few cases of this form of tumor have been re- ported and of these all occurred in the parotid. They raise the gland itself, are soft, and often lobulated. The diagnosis is seldom pos- sible before operation. 2. Mixed Tumors (Including Sarcomata). — It has been fre- quently observed that sarcomata of the salivary glands differed clini- cally from the same form of tumors as found elsewhere, both in their clinical and pathologic characteristics. Since the systematic- study of these tumors, by Hinsberg,^ Wilms," Wood^ and others, it has been found that the majority of tumors of the salivary glands belong to the class of mixed growths and that pure sarcomata are comparatively rare. Of fifty-nine cases examined by Wood, all but four belonged to the mixed tumors. They occui" about twice as frequently in the parotid as in the submaxillary and usually between the ages of twenty to forty. They contain elements from both the epiblast and mesoblast in most intimate relation to each other. The stroma contains embryonic connective tissue, cartilage, bone, fat, and lymphoid tissue. There is also epithe- lium present in about 24 per cent, of the cases. The mixed tumors of the salivary glands are found, as a rule, to be encapsulated, lobular growths, with harder and softer areas, the denser portions being due, as a rule, to the presence of cartilage or firm con- nective tissue. They can be divided macroscopically into three great rough groups with characteristic morphology and to a certain extent with a definite clinical course: 1. Very fibrous tumors with very little cellular structure and with but little mucous degeneration and no cartilage. 2. Very hard tumors containing large masses of cartilage and but little connective tissue or cellular parenchyma (Fig. 88). 3. Soft, very cellular growths with transparent trabeculas of mucous tissue surrounding areas which are opaque and yellow, which on micro- scopic examination will be found to be dense cellular areas, the color being occasionally, though not always, due to fatty degeneration or necrosis of the cells. The first and second forms are usually benign in their clinical course, while the third form is likely to recur locally or to pursue an ex- ceedingly malignant course. ^Hinsberg: "Deutsche Zeitschr. f. Chirurgie," Vol. 6i. ^ Wilms: "Deutsche Zeitschr. f. Chirurgie," Vol. 69. ^Wood: "Annals of Surgery," Jan. and Feb., 1904. 144 SURGICAL AFFECTIONS OF THE HEAD. The skin is freely movable over the benign gro^Yths. The ear may be distorted or pressed entirely backward by a large tumor in the parotid region, especially if the growth has extensions behind the angle of the jaw and is therefore unable to expand anteriorly. An average of the cases of mixed tumors in the Kterature shows that some 25 per cent, undergo changes which express themselves in a cHn- ically malignant\'ourse, while about 30 per cent, recur after operative Fig. 88. — CHON"DROSARC0iL\ OF Parotid Glant). Note how the tumor arises in the parotid region and extends toward and below the lower jaw and its nodulated surface. removal, though some of these recurrences may be checked by a second and more complete removal. The mahgnancy of these tumors can be judged to a certain extent by their slo\\Tiess of growth and their physical characteristics. The hard fibrous and cartilaginous tumors are apt to be benign, while the soft cellular tvpes are hkelv to prove mahgnant. But frequently a tumor which has remained for a long time quiescent wiU begin a most rapid growth, and in a few months increase in size more than during its entire previous existence. This sudden and rapid growth is accompanied AIFECTIOXS OF THE SALIVARY GLANDS. 145 by the clinical and microscopic evidences of malignancy, and the tumor spreads through the surrounding tissues, involves the skin and the sahvar}' glands, and may form metastases. Carcinomata of the Parotid. — These occur in people between forty and sixty years of age and are apt to be very painful. They may grow either slowly as a scirrhous form, causing considerable retraction of the skin, or as a medullar}^ form, growing ver}* rapidly and causing ulcera- tion of the overlying skin. Carcinomata of the parotid are apt to be ver}- painful and also cause early enlargement of the lymph-nodes of the neck on the corresponding side. The medullar}- form of carcinoma resembles greatly that of the same form of carcinoma of the breast. It grows ver}' rapidly and may occur at a comparatively early period, e. g., at the age of forty years, and is readily recognized not only by the rapidity of the growth, but from the early involvement of the skin. The latter is not movable over the tumor as in the other forms of parotid tumors. The scirrhus form re- sembles the scirrhus form of carcinoma of the breast, causing not only retraction of the skin of the parotid region but also an invasion of the skin itseh in the form of a diffuse carcinomatous lymphangitis, giving rise to the same variety of board-hke infiltration which occasionally occurs in carcinoma of the breast. To this latter condition the name armor-Hke cancer has been given. Diagnosis of the Tumors of the Parotid in General. — In attempting to make a diagnosis of tumor of the parotid one must bear the different groups in mind. Tumors of the parotid cause a characteristic prominence (Fig. 88) just in front of the ear, which latter is raised away from the head. They may either grow toward the neck, forming a ver}' prominent tumor, or toward the depth, that is, toward the pharynx. In some cases, enlargement of the parotid of an inflamma- tor}- nature, such as (a) retention-cysts, due to saHvar}- calcuh, (b) of the induration described as occurring in syphilis, or (c) enlarged lymph- nodes lying within and upon the parotid, must be excluded. Lymph-nodes have at times the consistency of the soft variety of mixed tumors. If they lie within the capsule and have enlarged rapidly, it may be almost impossible to. make a diagnosis. If, however, they He outside of the capsule they are movable upon the underlying parotid. As to the variety of tumors, those belonging to the first group of mixed tumors are usually quite small, not nodular, movable within the capsule of the gland, and give the historv'of having been present for a long time. Those of the second group of mixed tumors contain one-fourth of all the tumors appearing in the parotid. They are distinctly nodulated, 146 SURGICAL AFFECTIONS OF THE HEAD. have the characteristic consistency of cartilage and the history of long duration, as a rule, although a rapid increase in growth may sud- denly take place. A soft tumor usually belongs to the third group of mixed tumors. These are very cellular and give the history of comparatively rapid enlargement, or, on the other hand, they remain benign for a long time and then suddenly grow. The latter is very apt to happen after an operation. This third group has the consistency of inflamed lymph- nodes more than any of the others, but the inflamed lymph-node soon becomes softer and fluctuates distinctly while the neoplasm is more apt to grow steadily in size. Carcinomata of the parotid are exceedingly hard, occur late in life, and give the history of a steady, progressive enlargement of the gland with frequent ulceration of the overlying skin. In the differential diagnosis of tumors of the parotid, one must not forget (a) Hpomata lying within the capsule of the gland, (b) tumors of the temporo-maxillary joint, or (c) tumors of retropharyngeal origin growing toward the temporal fossa and pushing the parotid upward. Cystic tumors of the parotid give rise to distinct fluctuation, are of long duration, and must always be differentiated from those varieties of mixed tumor in which much myxomatous tissue is present which may give rise to a sense of pseudo-fluctuation. CHAPTER II. SURGICAL AFFECTIONS OF THE NECK. CONGENITAL AND ACQUIRED MALFORMATIONS. Thyroglossal Fistulae. — These are always found in the median hne of the neck. The external opening may be situated (a) just above the isthmus of the thyroid (Fig. 119), extending upward beneath the skin. The fistulous tract itself runs up behind the body of the hyoid where it may form a cyst, (b) It may extend through the substance of the tongue and form a cyst at the base of the tongue (Fig. 77). A fistulous opening situated in the median line of the neck should always arouse the suspicion of a patent thyroglossal duct. The only other congenital fistula? which occur in the neck are situated along the anterior border of the sternocleidomastoid. These lateral fistulae belong to the branchial variety and are referred to later. A thryoglossal fistulous tract extending from the isthmus of the thyroid to the inner surface of the body of the hyoid can be demonstrated by injecting colored fluids, such as methylene-blue, through the external opening. If the tract is pervious as far as the foramen cecum at the base of the tongue, the colored fluid will escape at the latter place. At times there is no ex- ternal opening, but only a dilated thyroglossal duct filled with fluid. Under these circumstances, the diagnosis can be readily made if one recalls the fact that the only other cyst which occurs in the. middle of the upper part of the neck is a dermoid cyst. This is usually situ- ated more. superficially and is more often in the submental region. It is also of larger size and of firmer, more doughy, consistency than a thyroglossal cyst. The diagnosis of thyroglossal cysts at the base of the tongue was taken up on page 138. Branchial Fistulae. — These are usually unilateral, and the external openings are more often situated just above the sternoclavicular joint or at the middle of the sternocleidomastoid. The internal open- ings are usually found on the tonsil, the lateral wall of the pharjux, or on the pillars of the fauces. The fistula may be complete, having Ijoth internal and external openings, or incomplete, having only an internal or external opening, as the case may be. The incomplete internal fistulas are fined with cyhndric, and the incomplete external 147 148 SURGICAL AFFECTIONS OF THE NECK. fistulas with squamous epithelium. From the external opening a small amount of mucus escapes. It may close, the secretion being retained, and suppuration occur. The course of a branchial fistula can be dem- onstrated, as in the case of thyroglossal fistula, by injecting colored fluids. It can be felt at times as a firm cord through the skin, ex- tending upward along the anterior border of the sternocleidomastoid toward the region of the tonsil. The deeper portions of a branchial fistula may dilate to form a cyst. Carcinoma may originate from the epithehum of branchial fistulse. Branchial cysts and branchiogenic carcinomata are discussed in the section upon tumors of the neck. The diagnosis of branchial fistulas may be made (a) from the fact that they usually occur in young individuals, (b) that their external opening is along the ex- ternal border of the sternocleido- mastoid muscle, and (c) the secre- tion is a thin, viscid mucus. In the absence of a suppurating lymph-node which might form a sinus here, the diagnosis is not difiicult. In the case of a sinus due to tubercular lymph-nodes, the edges of the sinus are often lined by flabby caseous granula- tion-tissue, which will readily serve to distinguish it from a congenital fistula. Cervical Rib. — Abnormal length of the transverse process of the seventh cervical vertebra not infrequently gives rise to symptoms caUing for surgical interference, so that it is important to be able to recognize its presence. The majority of the cases in which a diagnosis has been made during hfe have occurred in adults. The bony outgrowth is usually bilateral and can be palpated as a firm, bony tumor just above the inner end of the clavicles, running backward and upward toward the spine. Thirty-seven cases have been reported in which it has been rec- ognized during hfe, either through producing pressure on the subclavian artery or some of the branches of the branchial plexus. When the sub- FlG. 89. — Cervical Rib Outlined on Surface OF Neck. The cross indicates the tip of the rib. CONGENITAL AND ACQUIRED MALFORMATIONS. I49 clavian artery passes across a cervical rib, it may occasionally give rise to a pulsating tumor simulating an aneurysm. There is an absence, however, of the expansile pulsation characteristic of aneurysms in general, and a cervical rib producing such abnormal pulsation of the subclavian artery occurs at an earher period of life than do non-traumatic aneurysms. A skiagraph will confirm the suspicion that the pulsating tumor is simply the subclavian artery stretched over the end of a cervical rib. The effects on the arteries vary from weakness of the radial pulse to cyanosis. In extreme cases there is thrombosis of the peripheral vessels, resulting in gangrene. The nerve-pressure symptoms vary from neuralgic pain, situated in one of the branches of the brachial plexus, simulating at times a neuritis, to paresthesias and pareses of the muscles of the arm. Fig. 90. — Dissection of a Case of Cervical Rib. 7, Seventh cervical vertebra; i, first dorsal vertebra; 2, second dorsal vertebra. On the right side ob- serve the large cervical rib arising from the seventh cervical vertebra close to its junction with the first dorsal. On the left side observe a shorter cervical rib (Schultze). The diagnosis can be easily made by (a) the palpation of the bony tumor in the neck, (b) by disturbances of circulation, and (c) pressure symptoms upon the brachial plexus. The cervical rib may vary from a short projection an inch long to one extending to the first rib. It must be differentiated. chiefly from exostoses of the spine. These cause less pressure on the subclavian artery, but more on the vein, causing edema of the arm. The condition must also be differentiated from tuber- cular lymph-nodes in the posterior triangle of the neck. These nodes are never as hard as the cervical rib, nor arc they ever attached to the spine. Similar nodes are also to be found in the upper portions of the neck. A third condition from which a cervical rib must be differentiated is that of carcinomatous enlargement of the supracla\'icular glands, causing pressure on the surrounding structures. These may be very firm in ISO SURGICAL AFFECTIOXS OF THE XECK. consistency, but are never as hard as a cenical rib, and there is usually a histor}' of a primar}' growth or its presence at the time of examination in the territor}- drained by these nodes (Fig. 74). Wry-neck, or Caput Obstipum. — Wr}'-nec]^ produces a deformity wliich can be readily recognized by the fact that the head is inchned (Fig. 92) toward the side of the affected muscles, while the chin is directed toward the opposite side, and there is always some rotation of the head toward the opposite side. The chief point of surgical interest is to determine (a) whether the condition is of acute or chronic nature, or (b) Fig. 91. — X-RAY OF a Case of CER\acAL Rib. The rib itself has been outlined in black. whether it is s}Tiiptomatic or congenital in origin. Of the acute causes wliich may produce it the most frequent is muscular rheumatism. This form can be recognized by its sudden appearance, the absence of any swelling or tenderness along the muscle, with considerable pain on movement, and the histor}- of its having appeared quite acutely. Its form disappears rapidly after antirheumatic treatment. A second variety of acute wr}--ncck is that accompanying infection of the deep cer\dcal lymph-nodes (Fig. 92). This form is always accompanied by a swelling along the anterior or posterior borders of the muscle and there is considerable pain upon movement. The neck is held quite CONGENITAL AND ACQUIRED MALFORMATIONS. 151 rigid in the typical wry-neck position. Unless this swelHng be correctly interpreted as due to infection, the rigid position of the neck with rotation of the head, etc., may cause the suppuration to be overlooked. A symptomatic wry-neck posture is at times assumed by patients fol- lowing operations for extirpation of tubercular lymph-nodes, and may continue for some months. A fourth variety of wrv'-neck is that fol- lowing extensive bums or other cicatricial processes of the neck. It is often called the dermatogenous variety, to distinguish it from the simple or rheumatic, and the symptomatic forms just referred to. There is no difficulty in distin- guishing this form, owing to the fact that there is always ample evidence of scar tissue, either on the surface or in the subcu- taneous structures. A fifth form is that which occurs in children, the myogenic. It is due to rupture of and hematoma formation in the sternocleidomastoid mus- cle, and is known as the con- genital form. Congenital wr}'-neck is often accom- panied by a scohosis of the cendcal vertebrae, the con- vexity in the cendcal region being toward the side op- posite to that upon which the wry-neck is situated. It is not infrequently associ- ated with Hmitation of the visual field and facial hemiatrophy. A sixth form of wr}^-neck is that due to disease of the cervical vertebrae. In this there are neuralgic pains radiating from one or both sides of the verte- brae. There is also pain over the spine, stiffness, and the head is held in the typical fixed position. Wry-neck may also occur in a seventh form secondary to subluxation and rotation of the cervical vertebras. These cases always have a history of trauma and the spine is held rigid without any of the pain characteristic of tubercular processes, and the .r-ray may at times confirm the subluxation. Fig. 92. — Typical Wry-neck Position. Occurring as the result of suppuration of the deep cervical lymph-nodes. 152 SURGICAL AFFECTIONS OF THE NECK. An eighth form of wry-neck which may at times call for surgical interference is that in which there is a frequently recurring spasm of the sternocleidomastoid and trapezius muscles. This form is called spas- modic wry-neck. INJURIES OF THE NECK. Injuries of the various structures of the neck may occur as the result of suicidal attempts, of gunshot or stab wounds, or of fractures. The injuries to the veins, arteries, nerves, and thoracic duct occurring as the result of operation do not differ from those due to other modes of injury and will not be considered separately. Injuries to the Arteries. — These occur most often as the result of stab or gunshot wounds and may result in a partial or complete severing of the artery or in the formation of an aneurysm. The result of injuries of the arteries of the neck is either (a) immediate death, if the wound in the artery communicates with the wound in the skin, or (b) a large swelling forms in the neck in the immediate vicinity of the wounded artery, due to the escape of blood into the cellular tissue. Again, (c) death may occur at a later period through sloughing of the wall of an artery following a small wound of its wall, with resultant secondary hem- orrhage. The diagnosis of injury of the carotid artery may be made from the escape of bright red blood in large quantities through the external wound or the formation of a hematoma beneath the skin. There is no tem- poral pulse to be felt. In wounds of the subclavian arteries the same symptoms of tremendous primary hemorrhage or the formation of a hematoma may be present, accompanied by the absence of the radial pulse of the same side. The majority of cases of wounds of the arteries of the neck are not seen immediately, so that the diagnosis depends upon the location (a) of the subcutaneous hematoma, (b) the location of the wound, and (c) the fact that there is no pulse in the distal arteries. The vertebral artery is sometimes injured through gunshot wounds passing through the mouth or through a wound entering an inch below and behind the mastoid. At times the symptoms of injury of an artery may have been so slight at the time of the . accident that the swelling, if any was present, is overlooked, and the patient only pre- sents himself when a pulsating tumor has appeared as the result of the formation of a traumatic aneurysm. Traumatic Aneurysms. — The symptoms of both traumatic and spontaneous aneurysms of the neck are the same. In the former there INJURIES OF THE NECK. I53 is, however, the history of an injury, usually a gunshot or stab wound. The aneurysm may involve the artery alone or there may be communica- tion between the artery and the vein. The majority of traumatic aneu- rysms of the neck are found in the carotid artery. The diagnosis can be made by finding a pulsating tumor, usually situated close to the bifurcation of the common carotid artery, in which there is a thrill to be felt. If the aneurysmal tumor is compressed be- tween the index finger and thumb, one can feel a distinct expansile pulsation. Not infrequently the diagnosis is aided by finding symptoms (a) of compression upon the trachea, causing more or less dyspnea, (b) upon the esophagus, causing difficulty in swallowing, and of (c) pres- sure upon the hypoglossal or recurrent laryngeal nerves, causing diffi- culty in speech and hoarseness, respectively. There may also be symp- toms of pressure upon the nerves of the brachial plexus. In aneurysm of the external carotid the tumor is situated below the angle of the jaw and pushes the tonsil inward. At this point an aneurysm may be sim- ulated by a lymph-node lying upon the external carotid. Under these conditions the pulsation is only marked when the gland is pressed against the vessel and there is no expansile pulsation, as is the case in true aneurysm. Aneurysms of the subclavian artery may follow gunshot or stab wounds or rarely fractures of the clavicle, in which the fragments have penetrated the artery. Most often, however, aneurysms of this vessel are the result of endarteritis. The aneurysms of the first part of the subclavian artery are difficult to distinguish from those of the common carotid and innominate arteries, if on the right side. The aneurysms of the third part of the subclavian can be recognized by the presence of a pulsating tumor just above the clavicle, with the thrill, expansile pulsation, and bruit so characteristic of aneurysms elsewhere. An anreurysm of the subclavian artery must be differentiated from the condition referred to above, viz., the subclavian artery being stretched across a cervical rib and giving rise to a pulsating swelling, which may resemble an aneurysm. The absence of expansile pulsation and the de- tection of the elongated cervical rib serve to distinguish these. Subcla- vian aneurysms may also be distinguished by the fact that they are much more apt to give rise to symptoms of pressure on the nerves of the brachial plexus, causing either neuralgia or wcaloiess of the affected muscles. The most frequent location of aneurysms of the subclavian is in the third portion of the artery, situated on the outer side of the sternocleidomastoid muscle. Arterio-venous aneurysms as the result of trauma most frequently 154 SURGICAL AFFECTIONS OF THE XECK. involve the common carotid artery and internal jugular vein. The tumor is usually irregular and lirm, and it may be diminished but not en- tirely obliterated by pressure. There is an intense murmur and very marked thrill present, both of which disappear when the carotid is com- pressed just above the clavicle. Injuries of the Veins. — Injuries of the deeper veins, such as the innominate and subclavian, are most frequently the result of gunshot or stab v^'ounds. Those of the internal jugular and of the superficial veins of the neck, which pass across the median fine, are usually the result of attempts at suicide. The diagnosis of an injur}' of a vein may be made in the same manner as in the case of injury of an arter}'. In the case of wounds of a larger vein such severe hemorrhage may occur as to cause immediate death. A hematoma may form beneath the skin around the wound in the vein, and in the majority of cases the patient is seen in this condition. In wounds of the smaller veins air embolism may be the result. This condition is recognized from the presence of one of two groups of s}Tnptoms, either (a) a gurghng sound in the neighborhood of the wound, followed by immediate death, or (b) the onset of marked dyspnea, great anxiety, rapid and weak pulse, coma, and death within five to ten minutes. Wounds of the veins may be recognized, as was just mentioned, either by primary symptoms, such as the escape of blood externally, the position of the wound, and the history of a gunshot or stab wound or an attempt at suicide, or it may be recognized by the formation of a hematoma or the presence of symptoms of air embohsm. The secon- dary efi'ects of wounds of the veins are the formation of an arterio-venous aneurysm, if the wound in the vein communicates with the one in the artery. Another late result of injury to the vein is a secondary hemorrhage occurring from erosion of the vein. Injuries of the Nerves of the Neck. — Injuries of the vagus may occur as the result of gunshot or stab wounds or rarely following opera- tions. It can be recognized by the appearance of dyspnea and occas- ionally of hoarseness through severing of the recurrent lar}Tigeal. At times the injur}- of the vagus of one side will produce no s}Tiiptoms. The injur}' of both vagi results in aspiration pneumonia. Injuries of the sympathetic cause dilation of the pupil on the side of the injury if above the superior ganglion. Injuries oj the phrenic cause paralysis of the corresponding half of the diaphragm. Injuries of the brachial plexus ma}' occur as the result of violent blows, of fractures of the clavicle, after gunshot wounds, or as INJURIES OF THE NECK. I55 the result of severe traction on the shoulders during birth. This last- named form may appear in children under the cHnical picture of the Duchenne form of paralysis (Fig. 271). In this condition there has been laceration of the lowermost branches of the brachial plexus. A diagnosis of injuries of the brachial plexus may be made from the appearance of trophic disturbances, of paralyses with or without painful contractures, or of neuralgias of some of the branches of the plexus, following the injuries just referred to. Injuries oj the cervical nerves are very rare and usually cause only loss of sensation, transitory in nature, of the skin of the neck. Injury of the spinal accessory nerve often occurs as the result of operations in the posterior triangle of the neck. It may be recognized by the inabihty of the patient to raise the shoulder on the side of the injury (Fig. 11). Injuries of the Thoracic Duct.— This most often follows extir- pation of tumors or of lymph-nodes in the posterior triangle of the neck. It may be recognized by the escape of a thin, milky fluid from the wound, and may involve either the main duct itself or one of its branches. If it has persisted for some time, it causes considerable emaciation and weakness, due to the non-absorption of fat. Fractures of the Hyoid Bone. — These occur after attempts at strangulation or after being run over. It may be diagnosed by the presence of swelling over the hyoid, by severe pain referred to the same region, and from the dyspnea. Not infrequently there is also great difficulty in speech and in swallowing. Hemorrhage accom- panying coughing spells is also a frequent symptom. Fractures of the Larynx. — These occur as the result of choking, of gunshot wounds, and of attempts at suicide. On palpation one can find a deformity due to a dislocation of the cartilages of the larynx and also crepitus. There is often severe cough with bloody expectoration and other symptoms referred to under fractures of the hyoid bone. One can distinguish it from a fracture of the hyoid, however, by the greater cyanosis and dyspnea. One can often feel the ends of the bone pro- jecting through the overlying skin. Fractures of the Trachea. — These are comparatively rare. They are the result of stab or gunshot wounds or attempts at suicide. They may be recognized by the presence of symptoms of stenosis of the air passa^ges, such as stridor, dyspnea, asphyxia, and hoarseness. Not infrequently there is emphysema of the subcutaneous tissues. In wounds of the trachea following cut-throat, there is often suppuration of the surrounding tissue and secondary hemorrhage. The infection may 156 SURGICAL AFFECTIONS OF THE NECK. spread to the mediastinum. When the external wound is large, the diag- nosis of an injury of the trachea is easy. When it is small, one can only suspect it from the presence of subcutaneous emphysema and bloody expectoration. If the wound in the trachea communicates with a wound in the esophagus, food escapes through the wound in the trachea and is expectorated by the patient. Cut-throat. — The various conditions found in cases of cut-throat or attempts at suicide have been described in detail. A diagnosis may be made by considering the symptoms of injuries of the air passages, nerves, arteries, and veins just spoken of. The internal jugular or common carotid are seldom, if ever, injured. The typical place for the wound in the skin and deep parts is at the level of and through the cricothyroid membrane. If the wound passes into the larynx, it may sever the epiglottis and open the pharynx. At this level the lingual and superior thyroid arteries and veins and superior laryngeal nerve may be injured. If the wound is above the hyoid, the lingual and facial arteries and veins may be severed, and the tongue may fall back upon the epiglottis, causing asphyxia. If the wound is through or below the thyroid cartilage, the recurrent laryngeal may be severed, the trachea and esophagus cut across, and there may be marked asphyxia from entrance of blood into the trachea. The late complications of wounds at this latter level are cellulitis, mediastinitis, pneumonia, and fistulae of the trachea. FOREIGN BODIES IN THE AIR PASSAGES. The diagnosis of foreign bodies in the larynx must be made from the history and the presence of symptoms of stenosis or irritation. These latter are violent coughing, recurrent attacks of suffocation, cyanosis, hoarseness, or aphonia. The sputum is at first bloody and then puru- lent. If the foreign body is a solid one it may act as a ball- valve, being drawn downward during inspiration and pushed up during expiration. The symptoms of stenosis are in general most marked during in- spiration. Foreign Bodies in the Trachea or Bronchi. — The diagnosis depends (a) upon the history (one must ascertain how the foreign body entered the air passages) and (b) upon the presence of certain local symptoms. These latter are wheezing sounds in the bronchi, accom- panied by diminished respiratory movement upon the side on which the foreign body is situated, and diminished fremitus. Often there is partial or entire collapse of the corresponding lung. INFLAMMATORY PROCESSES. I57 In the case of metallic substances an x-ray picture will often show their exact location (Fig. 93). In the case of non-metallic substances one must depend upon a search for them with the bronchoscope, an instrument devised by Killian, INFLAMMATORY PROCESSES. Inflammatory processes in the neck may be either acute or chronic. The majority of the latter are tuberculous or actinomycotic in nature. The tuberculous form will be taken up in connection with inflammation Fig. 93. — X-RAY OE Safety Pin of Medium Size in Trachea Removed by Tracheotomy after Ineffectual Attempts to Use the Killian Bronchoscope. The outlines of the pin have been strengthened in black. of the lymph-nodes. Acute inflammatory processes may arise in the neck in four different ways : 1. Infection of wounds of the skin or soft parts. 2. Extension from infection in the mouth, or from the arm, or thorax, or spine. 3. Infection of the lymph-nodes (this is the most frecjuent form). 4. Metastatic (this is cjuite rare). The diagnosis of acute infective processes of the neck depends upon 158 SURGICAL AFFECTIONS OF THE NECK. a knowledge of the applied anatomy. This teaches that there are four places in which infection most frequently occurs, as follows : 1. In the submaxillary region. In this the submaxillary lymph- nodes lying within the pocket of deep fascia (Fig. 76) in which the submaxillary salivary gland is contained are affected, and from this focus the surrounding tissue is invaded. 2. The previsceral form. In this the tissue in front of the trachea and esophagus lying beneath the deep layer of the deep cervical fascia is involved. 3. The connective tissue along the carotid sheath. Infection occurs most frequently here from the lymph-nodes. 4. The space at the lower end of the sterno- cleidomastoid and just above the clavicle. I. Infection in the Submaxillary Region. — The diagnosis of infec- tion of the submaxillary region may be made from the presence of great swelling, of a tense infil- tration of the surround- ing tissues, and tender- ness. The swelling is accompanied by heat and redness. There is also dysphagia or difficulty in swallowing from pressure on the esophagus and dyspnea in the more extensive cases of infection. The dyspnea, owing to pressure on the larynx and trachea, may be even so severe as to cause edema of the glottis or asphyxia. The floor of the mouth is swollen and the tongue is elevated. In severe cases ulceration of the arteries, rarely of the veins, or a phle- bitis of the internal jugular may occur. If no surgical relief is given, suppuration may extend to the mediastinum along the previsceral or carotid sheath spaces. In ordinary cases of infection in this region the suppuration is simply confined to the lymph-nodes. 2. Previsceral Suppuration. — The majority of the infections of Fig. 94. — Mode of Extension of Infection in Deep Cervical Fascia. ST, Sternothyroid and hyoid muscles; S, sternocleidomastoid muscle; R and M, deep muscles at back of neck; Tr, trapezius muscle; V, body of cerwcal vertebra; C, structures of carotid sheath; E, esophagus; T, thyroid cartilage, and opening of larynx; VI, connective tissue of free visceral space (the black shading shows direction in which pus can spread) ; PV, mode of spreading of pus in prevertebral layer. INFLAMMATORY PROCESSES. 159 the cellular tissue of the previsceral space (Fig. 94) arise from the thyroid gland, or as extensions from suppuration in the submaxillary or carotid sheath spaces. The diagnosis can be made from the presence of edema, usually of a tense character, of redness, pain and the ordinary signs of infection, such as temperature, and, in the severer cases, symp- toms of sepsis. There is great danger of pressure on the tra- chea and esophagus, especially on the form- er, and of extension of the suppuration to the anterior mediastinum, with which this pre- visceral space com- municates. The pres- ence of this extension to the mediastinal con- nective tissue can be recognized by the con- tinuance of the tem- perature and evi- dences of sepsis after subsidence of the in- flammatory disturb- ances in the previsceral space, as well as the extension of the local inflammatory signs to the suprasternal fossa and the tissues over the sternum. This condition is referred to more fully in the chap- ter upon the thorax. 3. Suppuration in the Carotid Sheath Space. — The most fre- quent sources of infection of this space arc the lymph-nodes lying beneath the sternocleidomastoid muscles and along its anterior and posterior borders. These suppurative inflammations of the lymph- nodes are always secondary to a primary infective jocus in the ter- ritory drained by them. In the case of the upper internal jugular Fig. 95. — Portals of Infection and the most Frequent Nodes In- volved IN Tuberculosis of the Cervical Lymph-nodes. The arrows show the direction of the efferent lymph-vessels leading from the various portals of infection toward the respective nodes which are first infected: M, Uppermost node of internal jugular vein which receives the infective material from the ear; T, tonsillar gland located in angle of internal jugular and anterior jugular. This receives the lymph from the tonsil. From / downward are to be seen the principal lymph- nodes of the neck which receive the lymph from the head and face. These are the internal jugular group lying beneath the sternocleido- mastoid muscle in close relation to the internal jugular vein (F) and in direct connection with the lymph-nodes of the posterior triangle of the neck (P) . S, Submaxillary nodes. These lie either upon or within the capsule of the submaxillary salivary gland and receive the infective material from the teeth and jaws, but may be infected by retrograde cur- rents from the tonsillar lymph-nodes. C, Two nodes are shown mth their short venous branch leading into the internal jugular. l6o SURGICAL AFFECTIONS OF THE NECK. group the primary focus is usually to be found in the pharynx. It may, however, be the direct result of extension from infection of the submaxillary lymph-nodes. In the lower internal jugular group (Fig. 95) the infection may have had its origin in the skin of the supra- clavicular fossa. It is well to remember, from a diagnostic stand- point, that the primary focus in every form of suppurative lymph-node infection may have entirely healed and the presence of such a primary focus be forgotten by the patient when he is examined. In the case of the infective cellular inflammations along the carotid sheath, the patient presents himself with a swelling most marked either along the anterior or posterior border of the sternocleidomastoid. If the infection is extensive there is usually a wry-neck, referred to on page 151, edema of the overlying skin, dyspnea, and dysphagia. If the upper internal jugular set is affected, the swelhng is usually between the angle of the jaw and the sternocleidomastoid muscle. If the lower set is involved, the swelling is most marked at the posterior border of the muscle just above the clavicle. In severe cases there are symptoms of constitutional sepsis, such as high temperature, rapid pulse, a high degree of dehrium, and great prostration. In addition there may be dyspnea and difiiculty in swallowing through pressure on the trachea and esophagus. If the condition is not relieved, the pus will either escape to the surface and break through the skin, or find its way to the anterior mediastinum. Infection of the Superficial Structures of the Neck. The most frequent form of superficial infection which occurs in the skin of the neck is a furuncle, which m.ay occur at any portion, but especially in the region just beneath the superior curved line of the occipital bone, that is, at the nape of the neck. The area involved may be extensive, there being multiple foci of the suppuration. The term carbuncle is given to this form by the laity. The diagnosis of this condition is not diflicult. The chief point to be remembered, however, is the possibihty of the infection extending to the lymph-nodes along the carotid sheath or in the posterior triangle of the neck, referred to later. This infection of the lymph-nodes may be pres- ent quite early in an ordinary furuncle, as a nodular enlargement along the borders of the sternocleidomastoid muscle. This nodule will fre- quently subside as soon as the furuncle has healed. In other cases two or three weeks after heahng of the furuncle, these deep lymph- nodes begin to enlarge and suppurate. The diagnosis of this comph- cation is referred to later. . INFLAMMATORY PROCESSES. l6l A number of other infective inflammations occur in the neck, whose recognition is of great importance. The Woody Phlegmon, or Phlegmon Ligneux of Reclus. — This occurs either in the lateral or anterior regions of the neck. It is characterized by a very chronic course and involves a large area of skin and subcutaneous tissue. There are but few inflammatory symptoms. The skin is red and extremely hard, almost woody in consistency, hence the term woody phlegmon. Later this induration becomes softer and there is pus formation. Actinomycosis. — The neck is more frequently affected than any other portion of the body, after the jaw and teeth. The disease usually arises by direct extension from primary foci in the jaw or teeth. It can be recognized by the appearance of a slowly increasing, painless swell- ing in the submental and submaxillary regions, which is at first quite indurated, but soon softens, and the abscess breaks, leaving a sinus lined with flabby granulation-tissue, containing the characteristic yel- lowish granules. There is a distinct bluish color over the softer areas. The diagnosis can be made usually (a) from the history of the occurrence of similar abscesses around the jaw, (b) from the characteristic tense infiltration of the deeper connective tissue of the neck, with abscess and sinus formation. There are two conditions which must be differ- entiated from it. The first is tubercular inflammation of the lymph- nodes, and the second, tertiary syphilitic gummata. The former can be distinguished from the fact that the area involved by actinomycosis is larger than is the case in tuberculosis. Tuberculosis is usually hmited to certain definite groups of lymph- nodes, either the submental, submaxillary, or deep cervical, which, if they break down and form sinuses, differ in their external appear- ance from actinomycosis. The tubercular sinuses have undermined edges, and the granulations, although flabby, are often caseous in appearance. The finding of the actinomyccs in the yellow granules of the pus will confirm the diagnosis of actinomycosis. There is often a history of cattle infected with the disease, which the patient has been taking care of. From tertiary syphilitic gummata the differentiation is comparatively easy. These, when they give rise to ulceration of the skin, have indurated edges and the ulcer is usually extensive. The edges are sharp or steep and are not undermined. There is also a history of an initial lesion or the evidences of the disease elsewhere. l62 SURGICAL AFFECTIONS OF THE NECK. Affections of the Lymph-nodes of the Neck. These may be either primary or secondary, acute or chronic. The lymph-nodes of the neck, as elsewhere in the body, act as filters for infective agents brought to them from the territory which they drain. If one bears this in mind, the diagnosis of affections of the lymph-nodes in any portion of the body becomes much simpler and is a valuable diagnostic aid (Fig 95). Acute Inflammation. — With the exception of the quite rare acute Fig. 96. Bilateral enlargement of the submaxillary and parotid lymph-nodes in Hodgkin's disease. Fig. 97. — Side View of Patient with Hodgkin's Disease. Observe the large submaxillary glandular swelling as well as the relatively large size of the nodes lying over the parotid salivary gland. and subacute forms of tubercular inflammations of the cervical lymph- nodes, all of the acute infective processes belong to one of two groups. 1. Acute infection of the submaxillary and deep cervical or internal jugular lymph-nodes. These are almost invariably secondary to infec- tions of the tonsils, either the faucial or pharyngeal tonsil, or due to carious teeth. 2. Those of the deep cervical chain. These are either secondary to furuncles in the skin or to infective processes of the pharynx. The INFLAMMATORY PROCESSES. 163 diagnosis of botli of these forms is comparatively easy and has been re- ferred to on pages 158 and 159. Chronic Enlargements of the Cervical Lymph-nodes. — The cervical lymph-nodes are more frequently enlarged than those of any other portion of the body and in the majority of cases this is due to the tubercle bacillus. The different forms of chronic enlargements of the lymph-nodes of the neck belong to one of the following groups: (a) Simple hyperplastic lymph-node inflammation. Fig. 98. — Anterior View of Case of Marked Hodgkin's Disease. Fig. 99. — View of Case of Hodgkin's Disease. Showing both cervical and axillary node enlargement. (&) Tuberculosis of the cervical lymph-nodes : .1. The acute progressive form. 2. The subacute or pseudo-leukemic form. 3. The chronic form. - (c) Pseudo-leukemia or Hodgkin's disease. {d) Lymphatic leukemia. (e) Lymphosarcoma. (/) Secondary carcinomatous lymph-nodes. is) Syphihs of the cervical lymph-nodes. In examining any case in which by a process of exclusion of other forms of tumors of the neck (see page 172) one has arrived at the con- i64 SURGICAL AFFECTIONS OF THE NECK. Fig. ioo. — Primary Branchiogexic Carcinoma of Neck (anterior view). Observe the involvement of the skin at a point slightly distant from the original focus. clusioQ that the enlargement is due to the ]}TT!ph-nodes, the first question to be con- sidered is, are tliese lymph- nodes primary or secondary in nature? The majority oj all en- largements of the lymph- nodes oj the neck are secon- dary in nature, only a small percentage being primary. In this manner one can first exclude, in any given case, the so-called primary forms, which are as follows: {a) Lymphatic leukemia. (b) I/ymphosarcoma. (c) Pseudo-leukemia (Hodgkin's disease), or ma- lignant lymphoma. The chief characteristics of these primary enlargements are the following : Lymphatic Leukemia . — In this disease the enlargement of the lymph- nodes is usually quite ex- tensive, being distributed over both sides of the neck, as w^ell as over the axillary and inguinal regions. The glands themselves are soft and quite movable. There is no tendency to any ad- hesion of the individual glands to each other or to the surround- ing tissue. There is also no ten- dency to softening, as is the case w^ith tuberculous enlargements. The examination of the blood will show the presence of a very large number of lymphocytes, so yig. ioi.-lateral view of a case of br.^nchio- that the proportion of white to ^-^^'^ carcinoma of the neck; , , . . ^ . . Note the serpentine raised edges and the ulcerating red corpuscles, mstead oi bemg centers. INFLAMMATORY PROCESSES. 165 one to five hundred, is sometimes one to two. The disease may occa- sionally begin in a very acute manner with fever, etc. (acute lymphatic leukemia). Lymphosarcoma. — This disease usually begins in one node, which enlarges rapidly. The growth soon infiltrates the surrounding tissue Fig. 102. — Method of Examination for Enlargement of the Deep Cervical Lymph-nodes Along the Borders of the Sternocleidomastoid Muscle. Both patient and examiner should be seated, the latter sitting upon the right side of the patient, when the size and number of the nodes of the left side is to be determined and vice versa in the case of the right side. The patient's head should be grasped with one hand, while the other hand is inserted along the anterior border of the stemomastoid, the muscles of the neck being relaxed by bringing the patient's chin down somewhat toward the sternum. and there is early ulceration of the skin over the tumor. Very early in the disease there are evidences of metastases in distant parts of the body. The tumor is always movable on the deeper structures, so that it can be distinguished from sarcomata arising from these. The diag- nostic points are the rapid growth of the tumor and its firm consistency. i66 SURGICAL AFFECTIONS OF THE NECK. It is much harder than tuberculous lymph-nodes and has a marked tendency to ulceration. Pseudo-leukemia, or Hodgkin^s Disease. — This may occasionally appear in an acute form, but more frequently in a chronic. The nodes become enlarged at first on one side of the neck and soon afterward those of the other side are affected. This is accompanied by enlarge- ment of the axillary and inguinal lymph-nodes, and later of the bron- chial, mediastinal, and mesenteric. This form of enlargement of the lymph-nodes is progres- sive in character. It af- fects the lymph-nodes all over the body, usually more or less symmetri- cally. There is no ten- dency to suppuration al- though the lymph-nodes themselves are soft. They are easily movable in the surrounding tissue, and do not become adherent to the skin, which is mov- able over it. Often dif- ferent nodes of one group become adherent to each other, forming quite large tumors, which can be recognized as lymph- nodes by their nodulated, soft consistency and their location along the usual area of distribution of the cervical lymph-nodes. The enlargement is painless as a rule and not accompanied by temperature. The diagnosis of this form can be made from (a) the symmetrical distribution of the lymph-node enlargement, (b) the absence of any ten- dency to break down, and (c) the progressive involvement of lymph- nodes all over the body, which later in the disease cause pressure symptoms. These are dyspnea through pressure on the trachea, or dysphagia through pressure on the esophagus, or, in the abdomen, ascites. There is usually accompanying anemia and cachexia. There are no changes in Fig. 103. -Method or Determining Fluctuation in Suppu- rating Lymph-nodes of the Neck. INFLAMMATORY PROCESSES. 167 the blood except a progressive anemia, thus serving to distinguish it from lymphatic leukemia. There is great difficulty in differentiating a true case of pseudo-leukemia or maHgnant lymphoma (Hodgkin's dis- ease) from the pseudo-leukemic form of tuberculous inflammation of the lymph -nodes. This is referred to on page 171. If, in a case of enlargement of the lymph-nodes of the neck, one has excluded these three primary forms of lymph-node enlarge- ment, the diagnosis must be further made by excluding one after the other of the follow- ing secondary forms : (a) Carcinoma- tous. (b) Syphilitic. (c) Tubercular. (d) Simple hyper- plastic. (a) Carcinoma- tous. — These appear in the neck as an early manifestation of the presence of a carcin- oma in the respective territories drained by the cervical lymph- nodes (Fig. 95). The primary ,carcinoma may be comparatively easily found, so that the diagnosis is not difficult. But there are cases where the secondary lymph-node involvement is the first evidence that a carcinoma exists and this latter may be quite small. The characteristics of carcinomatous lymph-nodes are that they are extremely hard, the skin is movable over them, and they are easily ' movable upon the underlying and surrounding structures. The en- largement may be confined to the lymph-nodes of one region (Fig. 75), Fig. 104. — The Relation of Tdberculous Lymph-nodes of the Neck to the Sternocleidomastoid Muscle. I, Several large nodes which are fused together, lying in front of the muscle, extending as far forward as the angle of the jaw, the black area at the lower level of this mass indicates a sinus covered with tuberculous granulation-tissue; 2, a similar mass situated in the upper portion of the posterior cervical or occipital triangle, between the upper ends of the sternocleidomastoid and trapezius muscles; the sternocleidomastoid muscle usually lies superficial to such glandular masses, the latter being adherent to the deep vessels; 3, mass of nodes at lower portion of posterior cervical triangle (subclavian triangle); the black area at the center of this mass is a sinus similar to the one in relation to the other nodes; 4, outlines of sternocleidomastoid muscle. i68 SURGICAL AFFECTIONS OF THE NECK. for example, submaxillary or submental, or may be present on both sides of the neck. The diagnosis can be made (a) from the extremely firm consistency of the tumors situated in places where the various lymph-nodes are normally found, (&) the age— usually above forty, (c) presence of cachexia, (d) negative findings in the blood, and (e) the discovery of the primary focus. In the later stages, when ulceration of the overlying skin has taken place, the case may impress one as a primary carcinoma of the neck, but these are extremely rare, and are always due to a branchiogenic carcin- oma (Fig. loo). In some cases one is justi- fied in making a diag- nosis of a primary a;rowth if a careful search has failed to reveal any other pri- mary focus. The only conditions which could be confused with car- cinomatous lymph- nodes are those cases of primary branchio- genic carcinoma which have not broken through the skin. These are always deeply situated along the middle of the s t e rn o cleidomastoid, but differ from secondary carcinomatous lymph-nodes by being firmly attached to the deeper structures of the neck. In every case of suspected carcinomatous enlargement, one should examine systematically the various structures of the head where a primary carcinoma occurs, not omitting a search in the sinus pyriformis, anterior wall of the phar>Tix, and interior of the larynx. (b) Syphilitic Lymph-node Enlargement. — These occur in the primary stage, secondary to a chancre of the hps, tongue (Fig. 8i), or other forms of extragenital infection of the head or neck. The finding of the primary Fig. 105. — Tuberculous Lymph-nodes of the Neck. Observe the prominence just below and behind the angle of the jaw, to which the arrow points. The black area at the lower edge of the swelling and a similar area at the lower portion of the neck are two sinuses hned with yellowish granulation-tissue, characteristic of tuberculosis. INFLAMMATORY PROCESSES. 169 focus and its recognition as syphilitic in nature will render the diagnosis easy. In the secondary stage of syphihs there is occasional enlarge- ment of a few of the lymph-nodes of the neck. The presence of secon- dary eruptions on the skin or mucous membrane often accompanies this condition and in their absence the only forms which need to be differ- entiated from them in this stage are simple hyperplastic lymph-nodes, which are usually much firmer and smaller. In the tertiary stage one will encounter quite rarely, enlargement of the deep cervical or internal jugular lymph-nodes, which cannot be dis- tinguished, in the ab- sence of a history of syphilis, from simple hyperplastic or tuber- cular nodes until ulcer- ation of the skin has occurred. At such a time the aspect of the ulcer will clear up any doubt about the diag- nosis. It has the typi- cal appearance of the syphilitic processes in the tertiary stage. The edges are somewhat copper- colored and in- durated, but not as much so as in the case of a carcinoma. They show the characteris- tic steep edges of a syphihtic ulcer and the ulceration is always more extensive than in the case of tuberculosis. In doubtful cases the administration of iodid of potassium will cause a speedy healing of the enlarged gland or ulcer, as the case may be. (c) Tuberculous Lymph-node Enlargement. — As a rule, tuberculosis of the cervical lymph-nodes appears in a chronic form, with the following clini-cal picture: In the submaxillary region or along the anterior or posterior borders of the sternocleidomastoid, or in the posterior triangle of the neck, one linds slowly enlarging, soft, non-adherent tumors, which soon coalesce, becoming adherent to each other, and to the surrounding Fig. 106. — Enlargement of the Submental Lymph-nodes, the Result of Tuberculous Lymphadenitis. SURGICAL AFFECTIONS OF THE NECK. tissues and skin. This adhesion of the skin may not take place until the enlargement has become quite advanced. At an early period there is softening and pus formation and the caseous gland becomes adherent to the surface (Fig. 103), iluctuation becoming distinct. Unless surgical measures are undertaken at this stage, the pus discharges through the skin and a tubercular sinus forms. The diagnostic points of the chronic form of tuberculous lymph-nodes are the slowly-forming, soft tumors, which show a great tendency to softening and pus formation. There are no evidences of inflammation of the overlying skin until the node becomes adherent to it, when the skin becomes of a bluish color, and there is quite distinct fluctuation. Before making a positive diagnosis, however, of tu- berculous infection, a care- ful search should be made for primary foci such as a pharyngeal tonsil (adenoid vegetations) , or of enlarged caseous tonsils, or of a chronic middle ear sup- puration. These three are the most frequent in- fection atria for tubercu- lous cervical lymph- nodes. The less frequent ones are the teeth and tongue. If a sinus has formed, it can be recognized as tubercu- lous by its bluish under- mined edges and the presence of flabby, caseous granulations Hning the opening in the skin. This form of lymph-node enlargement occurs most frequently during the first twenty years of Hfe, but must be thought of in examining any case, even at a later period. The acute form is fortunately quite rare. The clinical picture is that of a rapid enlarge- ment of the submaxillary and deep cervical lymph-nodes, accompanied by a high continued fever, with morning remissions in some cases. In others there is only a moderate degree of fever. It can be differentiated from the other acute forms of infective lymph-node inflammation by the absence of a primary pus focus in the skin or mucous membrane. Fig. 107. — Distribution of Enlarged Lymph-nodes in a Case of the Pseudo-leukemic Form of .Tdbeecu- LOirs Lymph-nodes. INFLAMMATORY PROCESSES. 171 There is also less pain and swelKng of the surrounding structures. The nodes soon become adherent to each other, pus formation occurs, and the course of the disease, such as sinus formation and discharge through the skin, is the same as in the chronic form. During epidemics of so- called glandular fever, more properly called Pfeiffer's disease, such cases of acute tuberculous cervical lymph-nodes are apt to be interpreted as this disease, and vice versa. Pfeiffer's disease is usually accompanied by more constitutionalsymptoms,suchasa rapid pulse and higher temper- atures, there is httle tendency to breaking down of the glands, and they do not become adher- ent to each other. There is not infrequently the history of an epidemic of this disease. The pseudo-leukemic or subacute form of tuberculous lymph-node enlargement greatly resembles (Fig. 107) true pseudo-leukemia or malignant lymphoma. It involves not infrequently lymph-nodes on both sides of the neck as well as those of the axillary and ingui- nal regions, but there is not the same tendency to progres- sive enlargement as is the case with true pseudo-leukemia. The only crucial test in moder- ately advanced cases is by the excision of one of the nodes, and its inoculation into a guinea-pig. This pseudo-leukemic form of tuberculous lymph-node in- flammation has been fully described by Fischer. Its clinical recognition is of considerable importance, as many such cases are erroneously diag- nosed as true pseudo-leukemia: The characteristic difference between the two is the less marked enlargement of the lymph-nodes in tubercu- losis, the fact that the mediastinal and abdominal nodes are never in- volved, and that there are no pressure symptoms, anemia, or cachexia. The differentiation of chronic tuberculous l3^mph-nodes must be made (a) from syphihtic, (b) from mahgnant (most often lymphosarcoma, rarely carcinoma), (c) from pseudo-leukemic, and (d) from leukemic Fig. 108. — Anterior View of Location of Various Forms of Tumors of the Neck (diagrammatic). M, Dermoid cj'sts and enlargements of the submental nodes; 5, tumors and inflammatory enlargements of the submaxillary lymph-nodes and salivary glands; B, most frequent location of branchial cysts and parathyroids; C, enlargements of the deep cervical lymph-nodes; T, tumors of the thryoid; CR, cervical rib; A'', subclavian aneurysms; R. retrosternal goiter. 172 SURGICAL AFFECTIONS OF THE NECK, enlargement. This differentiation has been referred to under the separate groups. Simple Hyperplastic Lymph-nodes. — This last form of lymph-node enlargement is characterized by the presence of painless soft nodules, in the usual location of the cervical lymph-nodes. Rarely they are firmer in consistency. The diagnosis can be made from the fact that they are painless, show no tendency to breaking down, are freely mov- able, not matted together, and cause no symptoms. TUMORS OF THE NECK. Examination. — In examining a tumor of the neck for diagnostic purposes one should conduct the examination in a systematic manner as follows: 1. The history of the case. (a) The age of the patient. (&) When did the tumor appear ? Was it present at birth or shortly after? Did it appear at infancy, at or near puberty, middle or old age? (c) Has the growth of the tumor been rapid or slow? {d) Where did the tumor first show itself? (e) History of trauma, etc. (/) Is the tumor subject to attacks of inflammation? (This is frequently the case in lymphangiomata.) 2. Physical examination. A. Inspection: I. Location of the tumor. This is easy to note unless the tumor spreads over both sides of the neck. The various regions in which the tumors of the neck occur most frequently, are : (a) Submaxillary and submental regions (lymph-nodes, tumors of the jaw, dermoids of the floor of the mouth, bran- chial cysts, Hpomata). (&) Along the course of the trachea and the lar}Tix (goiter, thyroglossal cysts, thyrohyoid bursse). (c) Along the carotid sheath (lymph-nodes, sarcomata (deep), aneurysms, angiomata, branchial cysts and branchio- genic carcinomata, pressure diverticula of the esopha- gus). {d) Supraclavicular fossa (lymph-nodes, aneurysms, ostcomata, cervical rib). TUMORS OF THE NECK. 173 (e) Suprasternal fossa (retrosternal goiter and aneur>'sms). II. Consistency of the skin over the tumor. (a) Whether it is bluish or reddened, whether stretched or ad- herent, whether ulcerated or marked by dilated veins. B. Palpation: (a) The consistency of the tumor. Whether it is hard or soft, semi-fluctuating, or cystic. (b) Whether it is adherent or movable to the underlying tissues and skin covering it. (c) Its relation to the trachea as determined by the swallowing test (see page 185) — a symp- tom frequently pathognomonic of goiters. (d) Pressure symp- toms on the tra- chea, vessels, or nerves, and up- on the esopha- gus. (e) Examination for the presence of expansile pul- sation and thrill — a sign charac- teristic of an- eurysm. (/) Conchtion of sur- face of tumor, whether smooth Fig. log— Lateral View of Most Frequent Situ- ations OF Tumors of the Neck. P, Parotid tumors; 5, submaxillary neoplasms and lymph-node enlargements; T, enlargements of lateral lobes of thyroid; C, the many black areas correspond to the locations of the larger of the deep cervical nodes under the sternocleidomastoid muscle and in front of and behind it; A , lymph-nodes in posterior triangle of neck; N, subclavian aneurysm. or nodulated. (g) Whether larger af- ter eating and then smaller again as is the case in pressure diverticula of the esophagus. C. Examination of Blood, Spleen, Mouth, and of Body in General.^ In every case of tumor of the neck one should not omit the general examination of the patient. This should include (a) the mouth, ear, nose, and throat, with the aid of the special instruments required for these purposes; (b) the blood for evidences of leukemia, anemia, or leukocytosis; (c) the condition of lymph-nodes in other parts of the body, 174 SURGICAL AFFECTIONS OF THE XECK. e, g., the axillge, inguinal regions, peMs, and mesenten-; (d) the spleen, whether enlarged or not, as a part of the clinical picture of a pseudoleu- kemia or of some cases of lymphatic leukemia; (e) the presence or ab- sence of cachexia, etc. D. Auscultation and Percussion. — These are of Httle value in the diagnosis of tumors with the exception of the bruit heard over aneur}'sms of the common carotid and subclavian arteries. Classification. — Tumors of the neck are most conveniently divided into the cystic and solid varieties for diagnostic purposes. I. Those which are congenital in origin. Cystic. 1. Branchial cysts. 2. Th}Troglossal cysts. 3. Lymphangioma cysti- cum. 4. Hemangioma caverno- l sum and blood-cysts. 5. Th}Tohyoid bursae. 6. Cystic goiter. 7. Diverticula of the esophagus. II. Non-consenital . 8. Cysts of accessory or parathyroids. 9. Echinococcus cysts. ID. Sebaceous cysts. 11. Dermoid cysts. 12. Suppurating lymph- nodes (most often of a tuberculous nature). Solid. 1. Lipoma — diffuse or sym- metrical. 2. Fibroma. 3. Lymph-nodes — tubercu- lous, sj-philitic, or leu- kemic, lymphosarcoma (see page 165). 4. Osteoma. 5. Chondroma. 6. Sarcoma, including carotid tumors. 7. Carcinoma — Primar}-: From the skin or branchiogenic in origin. Secondar}-: To primary^ focus in head, lar}-nx, thyroid; esophagus, or breast. 8. Tumors of the submaxillary salivan.' gland. 9. Goiter, benign and malig- nant. ID. Aneurysms of common car- otid or subclavian arteries. 1 1 . Primary tumors of the paro- tid extending to the neck. 12. Accessory thyroids or para- th%Toids. Cystic Tumors. The chief characteristics of the various forms of cystic tumors of the neck are: I. Branchial Cyst. — These are generally located in the submaxil- lary region (Fig. no) or along the middle of the inner border of the sternocleidomastoid. It has the sensation of a tense cyst, is oval, and TUMORS OF THE NECK. 175 is firmly attached to the deeper tissues. The skin is movable over it Fig. iio. — Front View of Braxchtal Cyst. Fig. III. — Side View of a Unilocular Branxhial Cyst. Observe its position in the superior carotid triangle of the neck. 176 SURGICAL AFFECTIONS OF THE NECK. unless suppuration has occurred. They appear at birth but may not begin to enlarge sufficiently to be recognized until adult life. The contents may be serous, mucoid, or sebaceous. They are most often monocular. 2. Thyroglossal Cysts. — These are always in the median line between the hyoid bone and the middle of the trachea. They are monocular like the branchial cysts, are usually small, and move upward when the patient swallows. They cannot be distinguished from cystic lymphangioma, except by microscopic examination. 3. Congenital Cystic Lymphangioma. — These may occur either as monocular or multilocular tumors, most frequently situated in the submaxillary region. Less often they are found beneath the occi- put and in the supra- clavicular region. They arise from dilated lymph-vessels and vary from a small tumor to one occupying half of the neck (Fig. 112). They push their way like the hemangiomata between various struc- tures of the neck, but rarely cause compres- sion symptoms. They are, however, subject to recurrent attacks of in- flammation, during which they increase in size and the skin over them becomes reddened. They are almost always present at birth. They cannot be differen- tiated from those branchial cysts of the submaxillary region which are present at birth except by the fact that their contents is a clear serous fluid while that of the branchial cysts may be pure serum or mucus or sebaceous material with or without hair. 4. Hemangioma. — This variety of tumor occurs in two forms in the neck: (a) Simple and Cavernous Hemangiomata. — These are multilocular and may occupy one side of the neck (Fig. 112), contain blood and grow in all directions but rarely cause pressure symptoms. Fig. 112. — Congenital Cystic Lymph Hemangioma of Neck. TUMORS OF THE NECK. 177 (b) Unilocular or Blood-cysts. — They vary from a walnut to a child's head in size, are movable, and not attached to the skin. They often cause pressure symptoms such as dyspnea and dysphagia. They must be differentiated from aneurysms, cavernous angiomata, and lipomata. In the first-named there is a bruit, thrill, and expansile pulsation. In the cavernous angiomata there is a history of their presence at birth and they are multilocular. The lipoma is firmer and quite rare in the regions in which blood-cysts are found. 5. Thyrohyoid Bursae. — These occur most frequently over the thy- roid cartilage (bursa ante- thyroidea) or on the thyro- hyoid membrane. They are the size of a small nut and accompany the movements of the thyroid in swallowing, and are apt to be painful at times in rheumatic persons. They must be differentiated from cysts of an aberrant thyroid. 6. Cystic Goiter.— This usually involves one or both of the lateral lobes of the thy- roid. It may be of large size and cause considerable ele- vation of the skin (Fig. 113). It gives a distinct sense of fluctuation. 7. Diverticula of the pharynx or esophagus are always on the left side and there is a history of their alternately full and empty condition. They are quite rare in the neck. 8. Cysts of the Accessory Thyroids and of Parathyroids.— These are found in the typical location of these structures (Fig. 108) and are quite small and appear usually after the age of puberty. 9. Echinococcus cysts are quite rare and are found close to the sheath of the carotid vessels or in the stemomastoid itself. They cannot be differentiated from tuberculous lymph-node abscesses except from the history of a solid tumor which has softened and is quite adherent. This speaks for tuberculosis. Fig. 113. — Anterior View of an Enormous Cystic Goiter. It occupied all the space between the sternocleido- mastoid muscle on either side, the lower jaw above, and the sternum below, and contained a brownish gelatinous fluid with cholesterin crystals. 178 SURGICAL AFFECTIONS OF THE NECK, 10. Sebaceous Cysts. — These are quite superficial, small, and stretch the overlying skin over it considerably. They may also be adherent to the skin. 11. Dermoid cysts occur in the median line, especially just below the chin. They are firmer and more doughy in consistency than any of the other cysts occurring in these locations. Solid Tumors. 1. Lipoma ta. — These usually occur at the back of the neck as subcutaneous soft tumors, not adherent to the skin. They are usually more or less fixed at their base and when the skin is stretched over them during examination, showing a dis- tinct diversion into lobules. They may attain an enor- mous size. A form of diffuse lipoma (Fig. 115) may occur in which the fatty tissue grows indiscriminately between the other structures of the neck, burrowing between the muscles and vessels. This condition may be present in connection with a peculiar form of multiple fatty tumors situated more or less symmetrically over the entire body and called symmetrical lipomatosis. A deep or subfascial form also rarely occurs which simulates the softer forms of sohd tumors, such as goiter or tense cystic tumors. 2. Chrondromata are very rare and arise from aberrant islands of cartilage. The skin is movable over them and their firm consistence, hke that of the cartilage of the nose, renders their diagnosis easy. They occur in young people. 3. Osteomata usually occur in the lower part of the neck as out- growths from the spine, ribs, and clavicles. Their bone-Hke consistency, location, and fixation aid in differentiating them from every other Fig. 114. — Large Cystic Goiter. Extending from level of lower jaw almost to sternum. This patient also had a marked kyphosis, due to old age. (Side view of same patient shown in Fig. 113.) TUMORS OF THE NECK. 179 form of solid tumors, even without the use of the x-ray. The only condition which resembles an osteoma at the base of the neck is a cervi- cal rib, which was described on page 148. Such a supernumerary rib is thinner and more frequently causes pressure of the adjacent nerves and vessels than an osteoma. 4. Fibromata. — These usually occur as soft pedunculated tumors of the skin, often associated with a generalized condition of fibroma molluscum (Fig. 376). 5. Solid Tumors of the Submaxillary Salivary Gland (Fig. 116). — These appear in the typical location of the submaxillary salivary gland on the inner side of the body of the lower jaw close to the angle. They are either chondromata or mixed tumors and must be differentiated from enlarge- ment of the submaxillary lymph-nodes due to tuberculosis or malignant disease (such as carcinoma). The former may be excluded by the firm consistency of the tumor and the latter by the absence of a primary growth. 6. Goiter. — Here the tumor is situ- ated in the region usually occupied by the thyroid gland along either side and across the middle of the trachea (Fig. 119). It may be soft or quite firm, varying in this respect according to whether it is parenchymatous, colloid, or fibrous in character. When the patient swallows a glass of water the tumor moves upward on account of its attachment to the trachea. The skin is movable over the tumor. Goiter is considered in detail on page 185. 7. Sarcomata. — These arise in the deeper parts of the neck and grow toward the surface. They may arise from the following struc- tures : (a) The carotid body. (b) The connective tissue of the carotid sheath. (c) As lymphosarcomata from the cervical lymph-nodes. (d) From the thyroid gland. Fig. 115. — Symmetrical Lipomatosis. In this case the entire neck from the sternocleidomastoid on each side was oc- cupied by a diffuse hpomatous tumor. Li- pomata were distributed symmetrically over both deltoid regions, over the abdomen on either side of the median line, and over both gluteal regions. I50 SURGICAL AFFECTIONS OF THE NECK. (a) Sarcomata Arising from the Carotid Body (also called Luschka's gland). — They are usually endotheliomata and appear in middle-aged or old people. The tumor is of ver^^ rapid growth and is situated at the point of bifurcation of the common carotid artery. It invades the vessel sheath in its growth. The tumor is soft and compressible, attain- ing the size of a hen's egg, and shows no expansile pulsation or thrill like Fig. ii6. — Solid Tumor of tiee Submaxillary Salivary Gland. This illustration shows how these tumors appear to come from behind the lower jaw, projecting outward in the submaxillary -region. (See text.) an aneurysm. It is much firmer than a branchial cyst, appears at a later period in life, and grows more rapidly. It has a transmitted pulsation due to its relation to the vessels. (b) Sarcomata arising jrom the carotid sheath itself grow rapidly and are firmly fixed to the deeper structures of the neck, although they are not adherent to the skin until a later period when they may ulcerate and TUMORS OF THE NECK. I«I present a sloughing mass. They cause pressure symptoms such as dysphagia, dyspnea, neuralgia, and recurrent laryngeal paralysis at an early stage of their growth. They are of firm consistency and usually occur in middle or old age. Their location under the sternocleidomastoid muscle, rapid growth, fixation to the deep structures, and pressure symptoms render their diagnosis comparatively easy. Lymphosarcomata and sarcoma of the thyroid are discussed on page 187. 9. Carcinoma. — This form of tumor of the neck may be primary or secondary. The former are very rare and may arise in the skin either (a) from an old ulcer or a scar or (b) in the deeper tissue from the branchial cysts or fistulae or from aberrant thyroids. (a) Primary Carcinoma. — The cutaneous carcinomata pre- sent the same characteristics as elsewhere. The deeper forms of primary carcinoma are usu- ally rapid in their growth and located just below the angle of the jaw or at the middle of the sternocleidomastoid muscle at the same location as the branch- ial cyst (Fig. 100). They occur late in life and become adherent to the vessels early and cause ul- ceration of the skin, with evert- ed hard edges (Fig. loi). The diagnosis of a primary branchiogcnic carcinoma may be made if the growth has the typical induration of carcinoma, situated in the usual cyst location of a branchial cyst. They are fixed and cause pressure symptoms only at a late period. The growth is harder than a sarcoma and there is often involvement of the regional lymph-nodes (deep cervical). Primary carcinoma of the thyroid is lower in the neck and attached to the trachea and displaces the latter (Fig. 117). (&) Secondary Carcinoma. — This form of solid tumor can be readily Fig. 117. — Anterior View of Carcinoma of the Thyroid. Causing displacement of the trachea {T) to the left: G, Secondary enlargement of the cervical lymph- nodes, of a carcinomatous nature. SURGICAL AFFECTIONS OF THE NECK. diagnosed from the fact that it involves the lymph-nodes draining the mouth, nose, ear, pharynx, or thyroid (Fig. 74). They are very hard, cause early pressure symptoms, and hke the sarcomata and primary carcinomata ulcerate quite early. The diagnosis can be made from the consistency of the tumor and its location. The latter corresponds with that of the lymph-nodes. One should search for a primary growth in the head, larynx, esophagus and thyroid, breast or stomach (supra- clavicular nodes). The latter is a rare occurrence. At times the external tumors may be enormous and even bilateral and the primary growth be an insignificant one, hid- den in some obscure place like the sinus pyriformis or the anterior wall of the pharynx. One should always examine in their order the face, mouth, tongue, nasopharynx, lar- ynx, esophagus, ear, sal- ivary glands, thyroid, and rarely the stomach. Primary carcinoma of the esophagus may at times first involve the submaxillary nodes to such an extent that the tumor is diagnosed as a primary one of the sub- maxillary salivary gland. The secondary car- ciQomatous nodes are often movable and painless for a considerable period and may be the first sign to direct suspicion toward a malignant growth in the region which they drain. They are much firmer than tuberculous nodes and the latter are very rare at such a late period of hfe. Primary branchiogenic carcinomata, as was stated above, become adherent quite early to the vessels and cause severe pain. Fig. 118. — Lateral View of Case of Carcinoma of the Thyroid. TUMORS OF THE NECK. 183 > ,n «^ 77^ > -h %--^ bb T32 C ^ 3 3 u 5 rt rl u 3 n D "S >.^ a u p s 3 ^ ill, .S ^ ii be 3 .tl J^ E _0 'S u "0 C/3 >+H P^, 17 ^^.^ Td -^ .3 tfi C3 _1 " O O ^ i-M *^ > ^ ^ (^3 U .3 ^-^ •,-• en Pm £ ■" c« rf O >> ^,U « d O " 12 "^ o .2 "^ bJD'S (Ti *+-< i ° 3-13 in ae^ 3 ■2'o T3 :n .4:J 3 o < .2 "B '5b o 0.2 3 > t- o c3-^ 1-1 *^ ^ S 6< VI u cAi rt I -^ O o " < ^ £ o ^ 3 3 b£ 3 bO H u i84 SURGICAL AFFECTIONS OF THE NECK. X u >-. i J: o 3 c o ■55 p; accord hymato maligna o cfi •^ B u >. £ 3 b ^ C t-i 1) o • c 3 en u >^ u C o Grows rapidly, varies from soft hard and d infectio s in prima ."2 e stenry var hcther pai id, fibrous. i; o E >. o > c U Very gion node Consi to w collo ■ r^ !/} r- 3 U o c c > 1) O C "- o g i s W (il None unless fuse variety i C None exce Hoflgkin's c or lymphosa None exce])t ralgic pains, slow growth i Quite early sure on tr e s p h a g u vessels. Same as abo-v primary a growth. Lat sure sympto secondary. m T; 3 d ^ d in -^ ^ C in 13 S -3 S c 3 > ) in in cS • >^ ^^ rf 3 XI •s a .S S i 3h .^ .g 1n g X d S S ii u 3 . d kS (u 2 ^ 2 -^ 03 d 4j^ < 3 < 3 < 6 c < 3 < d in C < < bO d 3 < a, 3 bO . !5 H H H tn ^3 '-/J § 3 go ^ C r^ rt bC -^ 2 . c o-o ^ ^ c c ^ > -s . a =1 i £; 3 ^ "o in C In s d to: i^ .5 •-' ^S" g " b in'^ g 33 L, C "B^^ ! ^ ° S ■i - ! y In ^ a. o- > ^ -^ € ^' 3 3d c d _o "0 « > X. ^ i t 6 d in U D 1^ g 5 3 6 c a en . c r^ 1 'in I 4 s c u 1 5 E d 1 . d d E c _c '5 d u _d d E . «J d ■^"bb if) ^ 11 OC" aj , 3 TUMORS OF THE NECK, l8 = XJ V I c bO a 03 3 u ^ 1-. u ■*-• aj .2 .^ j2 *■*-» Pl . 3 rt (1; /^ -r) t/3 3 o Oh •rt S I- n! c S M=l lO, o f^3 a" ^^ > (U ^^x) -0 A 1 1/1 "c 'c O c/1 ^ ^ !-( S& J g 3 O rt O rt b„ ^- ^- ^ T3 .2 < • ^ Dh Qj 0) > o rt +j >-. c3 > c3 O -73 O ^ eg -5 C O Id tn .S fe a M ,fl -.'-' tn ai CO ti< C/3 _>^ n! 3 tn 3 3 ,0 aT bC^J 3 3 X) -o < < . lA M a E CJ 'S CU aj ^ aj en 3 S^ i/i d dJ u ^ o ^ 12 O 'S 1 3 O nj c ii '|~! o •- C c« bD e; o C ■^Tr,'^ O ?f t« ^ o < < "" 1 t-f oj o fl, •s i" s^ o y^f ■^ cS X) , „ rC t' feT5 3 1-. i- .C o a, < Ph O 6 M 1 <^ i •-* M k-< Non-malignant Goiter. This may involve the thyroid gland proper, or one of the accessory thyroids or parathyroids. The pathologic changes are the same in all and the diagnosis of which one is involved can only be made from the location (Fig. io8). The chief questions in every case of non-mahg- nant goiter are: (a) Whether the suspected tumor is a goiter. (b) What is the extent of the involvement and the variety? (c) Are pressure symptoms present? A goiter of the accessory or parathyroids will have all the clinical characteristics of the true goiter, but its situation is different and it is not attached to the trachea. A goiter, involving the thyroid gland proper causes a prominence in the lower portion of the neck (Fig. 119) best seen when looked at from the side. It may be most marked in the median line if it involves the isthmus or more on one side if one lobe is involved, or be butterfly-hke causing a prominence on both sides connected by a bridge (Fig. 119). Tumors of the thyroid, unless a brawny, board- hke infiltration exists, move upward with the tra- chea. This can be determined by permitting the patient to swallow some water while the tumor is grasped with the fingers (Fig. 121). This is ab- sent in goiters of the para- or accessory thyroids. The extent of involvement can be ascertained by flexing the head upon the neck and palpating the tumor while standing behind the patient. The varieties of enlargement are: I. Simple Parenchymatous. — This occurs at any age but is especially frequent in young people. It usually involves the entire gland, is soft and smooth, and rarely causes pressure symptoms. It may give the sensation of fluctuation. Any of the other forms may develop in it. It may begin during adolescence or pregnancy and remain stationary. SURGICAL AFFECTIONS OF THE NECK. 2. Thyroid Adenoma. — This is the most frequent form. It causes firm nodular tumors whose outhnes are quite sharp. It often contains small cysts and its acini, which resemble those of the normal thyroids, may coalesce to form large fluctuating cysts form- ing very prominent tu- mors (Fig. 113). This form (adenoma) involves only a portion of the gland, either one lobe (Fig. 122) or the isthmus. Pressure symptoms such as dyspnea are marked if it compresses the tra- chea. If smaller or larger collections of col- loid material occur it gives it a doughy con- sistency. 3. Fibrous Goiters. — These occur as enormously hard nodules or as a diffuse induration of one lobe or of the entire gland. In the latter form they cause pressure symptoms quite early. 4. Vascular Goiters. — This variety presents a distinct pulsation or thrill of the goiter due to the enlargement of the vessels. There are murmurs to be heard over the tumor. Pressure symptoms are most marked if the posterior part of one or both lateral lobes are involved, or if there is a retrosternal goiter. These pressure symptoms are: (a) Those due to pressure on the trachea. If moderate there is dysp- nea, cyanosis, and some stridor. If the pressure is of high degree asphyxia may result (Fig. 117). Fig. 119. — Parenchymatous Goiter. Causing enlargement of right (i?) and left (i) lateral lobes and isthmus {M) of thyroid. The palpable outlines of the tumor are traced upon the neck in black. Fig. 120. — Lateral View of Same Case Shown in Fig. iig, of Parenchymatous Goiter Involving Isthmus and Lat- eral Lobes. TUMORS OF THE NECK. 187 y. The extent of this pressure on the trachea may be ascertained by a laryngoscopic examination and tlie use of the x-ray as recently sug- gested by von Bruns. (b) Pressure on the recurrent laryngeal nerve. This causes hoarse- ness, a brassy cough, and aphonia. Death may ensue suddenly from spasm of the glottis. (c) Pressure on the sympathetic causes vasomotor disturbances of the skin of the face and neck and a dilatation of the pupil on the side upon which pressure is exerted. (d) Pressure on the esophagus is less frequent than any of the above and results in diiSculty in swallowing. A retrosternal goiter produces dullness over the manubrium (Fig. 148), may cause pressure on the trachea, and this tracheal stenosis be the only symptom. It may also compress the large veins, the innominate ar- tery, and the esophagus. A retrosternal goiter must be differentiated from other conditions, such as other varieties of mediastinal tumor, such as sarcomata, aneurysms, and esophageal divertic- ula which could produce the same symptoms (see page 329). In retro- sternal goiter the dyspnea is intermittent, varying with the rise and fall of the tumor during respiration. ./ Fig. 121. — Method of Grasping Tumors of the Thyroid to SHOW their Relation to the Trachea. The lobes of the enlarged thyroid are grasped between the index-finger and thumb, and the patient instructed to swallow. During the act of swallowing the tumor moves distinctly upward, and sinks again after cessation of the same. Malignant Goiter. Both sarcoma and carcinoma occur rather infrequently. Sarcoma occurs at an earher age (thirty to fifty) than carcinoma (forty to SURGICAL AFFECTIOXS OF THE NECK. sixty). Sarcoma grows more rapidly than carcinoma and attains a much larger size. Both can be distinguished from non-malignant goiters by the fact that they cause a steady, at times quite rapid, enlarge- ment of the gland and the pressure symptoms on trachea, esophagus, and blood-vessels are ver}' marked (Fig. 117). Both forms of tumor are much harder than the ordinary forms of goiter. Sarcoma causes a uniformly rapid enlargement while carcinoma is quite nodulated, accom- panied by enlarged hard lymph-nodes, and is very painful. Carcinoma of the thy- roid produces early metas- tases in the long bones and skull. Thyroiditis. Inflammations both of the normal thyroid gland and of a goiter may occur. The symptoms are identi- cal in both. They may follow injury to the neck in the vicinity of the gland or occur dur- ing the course of some general disease, such as typhoid, malaria, articular rheumatism, scarlatina, variola, and pyemia. The diagnosis presents no dif- ficulties if one remembers the normal situation of the The gland can be felt to be considerably swollen and in- It is quite tender and the pains radiate toward the face and In the very acute cases there is redness of the overlying skin. The leukocytosis, pulse-rate, and temperature vary with the severity of the infection, being higher in the very acute cases. The swollen gland may compress the trachea and esophagus and cause symptoms of stenosis, dyspnea, and dysphagia respectively. If the inflammation goes on to suppuration the surrounding tissue becomes edematous and tender and pus forms in the gland. This may be ascertained by the persistence of the temperature and the increase of the local signs and leukocytosis. y Fig. 122. — Unilateral Right-sided Goiter. The arrow points to the tumor along the inner side of the lower portion of the sternocleidomastoid muscle, caused by the goiter. thyroid. durated the ear. TUMORS OF THE NECK. 189 The pus may escape externally through perforation of the skin or rupture into the trachea, esophagus, or mediastinum. Exophthalmic Goiter. The diagnosis of this condition may be made from the presence of a group of four symptoms, exophthalmos, tachycardia, a goiter, and a fine tremor. It may occur as a disease without any marked enlargement of the thyroid or be accompanied by any of the forms of goiter. Fig. 123. — Front View of Case of Exophthalmic Goiter. The bulging of the eye resulting in abnormal separation of the lids is well shown. The thyroid was greatly enlarged, of the parenchymatous variety, and involved both right and left lobes and the isthmus oi the thyroid, all of which were quite prominent. The pulse-rate in this case was 152. Fig. 124. — Side View of Case of Exoph- thalmic Goiter. Note the protrusion of the eyeballs and the marked prominence over the thyroid region, due to the presence of a parenchymatous goiter of both lobes and isthmus of the thyroid. The exophthalmos is bilateral and (Figs. 123 and 124) accompanied by certain typical ocular symptoms which, however, are not constant. These latter are the Stellwag symptom (abnormal wideness of the palpebral opening), the Moebius symptom (a lack of convergence of the two eyes), and the von Graefe symptom (the upper lid does not follow the eyeball when it is moved down). The tachycardia varies from ninety to one hundred and forty beats or even higher in severe cases. The face and neck are Hushed and there are frequent attacks of profuse sweating, especially of the extremities. 190 SURGICAL AFFECTIONS OF THE NECK. The goiter is moderately firm, not as large as in ordinary cases, and often so vascular as to show a distinct bruit. The tremor is of a very fine character, best seen when the hands are extended. There is often great muscular weakness (myasthenia). From time to time there are attacks of vomiting and diarrhea as well as of palpitation and angina pectoris. The lan^al or formes frustes often accompany goiters, but are apt to be overlooked. In these, any of the above symptoms, such as tachy- cardia, tremor, sweating, and palpitation, may accompany a goiter and not be correctly interpreted. Edema of the Glottis. This is usually secondar}' to inflammmatory conditions in the vicinity spreading to the loose connective tissue of the aryepiglottic folds. The swelling causes marked dyspnea, cyanosis, and stridor. The s}Tnptoms may appear so rapidly that death occurs immediately. The diagnosis may be made from the onset of the above symptoms during the course of a peritonsillar (Fig. 1 25) or perichondritic suppuration or as a comph cation of a Lud wig's angina (deep phlegmon of floor of mouth) or of ulcerative laryngeal processes. The diagnosis can be confirmed by lar}Tigoscopic examination. One can see the swollen aryepiglottic folds almost touching each other. #■ Fig. -Peritonsillar Abscess. PA , Prominence along anterior pillar of fauces and caused by peritonsillar abscess; SP, edema- tous uvula; L, normal left tonsil and pillars of fauces; T, tongue. Papilloma of Larynx. This is the most frequent form of benign tumor of the larynx. They occur especially in children on the true vocal cords and are usually multiple. They give rise to S3'mptoms of stenosis and hoarseness and if pedunculated may fall mto the space between the cords and cause asphyxia. By laryngoscopic examination they look like a pink mul- berr}^-shaped tumor situated at the anterior end of one of the vocal cords or scattered diffusely over both the cords. TUMORS OF THE NECK. I9I Carcinoma of the Larynx. Carcinoma of the lar}Tix usually occurs late in life. It may be primary, i. e., have its origin within the larynx, or secondary, by extend- ing to it from the tongue, pharynx, or esophagus. The primary is also spoken of as intrinsic, the secondary as the extrinsic form. The diagnosis may be made from the gradual onset of hoarseness, pain in the lar}Tix radiating to the ears, and dyspnea in elderly men taken in conjunction with the local findings. Later on when the lymph- nodes along the anterior border of the stemomastoid become enlarged and there is expectoration of a fetid, tenacious mucus, with recurrent hemorrhages accompanied by dysphagia and emaciation, the diagnosis is no longer difficult. The local examination at an early stage, will show one of the follow- ing lar}Tigoscopic pictures: 1. A papillomatous growth which has a broad indurated base situated usually on the posterior third of a vocal cord. 2. As a marked thickening and induration of one of the vocal or ventricular bands or aryepiglottic folds. At times one sees in addition to the induration a nodulated condition. The entire thickness of the cord seems to be involved. Later in the disease, the picture is different; one now sees ulcerations with raised and indurated edges. The car- cinoma has now begun to grow either through or around the thyroid cartilage and is to be felt externally as a hard mass accompanied by firm enlarged lymph-nodes. In the very advanced stages it may grow toward the trachea, phar}mx, or esophagus, and cause corresponding symptoms. There are a number of conditions from which carcinoma of the larynx must be differentiated. These are benign papilloma, syphilis, and tuberculosis. The first-named occurs very rarely so late in life and according to Bland Sutton any papilloma beyond the age of forty must be looked upon with suspicion. In regard to the two last-named conditions, tuberculosis and syphihs are always seen as ulcers and seldom as infiltrations and never papil- lomata. In tuberculosis severe' pain, cough, and dysphagia are promi- nent symptoms. The arytenoids are greatly swollen and club-shaped. The tuberculous ulceration is very shallow, has no indurated edges, and the larynx is very anemic. Tuberculosis is never primary and is accompanied by signs of pulmonary disease with tubercle bacilli in the sputum. Tuberculous ulcers are multiple while carcinoma occurs in a single place. Tuberculosis has as a favorite seat the interarytenoid 192 SURGICAL AFFECTIONS OF THE NECK. space or the antenoid cartilages. Syphilis is accompanied by signs of the same disease elsewhere and if iodids are given there is marked improvement of the lar}Tigeal condition which causes hoarseness and dyspnea as does carcinoma. The syphihtic ulcerations as elsewhere are deep and the edges are clear cut as though cut out with a die, and may occur anywhere in the larynx, but Hke tuberculosis are usually multiple. There is no enlargement of the lymph-nodes of the neck. It must not be forgotten that as on the tongue carcinoma may be combined with syphihs. It is almost impossible to diagnose such cases. CHAPTER III. THORAX. Injuries of the Bony Walls of the Thorax. The diagnosis of whether an injury has occurred and its extent can only be made from a systematic examination of each rib, of its costal cartilages, and of the sternum. FRACTURES OF THE RIBS. If the mode of injury has been a blow received from some blunt object or a fall upon the same, the fracture will usually be found at the point of impact. If the thorax has been crushed in a diffuse manner, as in being run over or caught between bumpers, the fracture will usually be found between the midaxillary line and angle of the ribs. Those most often broken are from the third to ninth ribs inclusive. Only one rib may be broken or a number (six or seven). A single rib may at times be broken in places. The diagnosis of whether there are complications, such as injury of the vessels, pleura, or lung, will be considered on page 196. The diagnosis of a fracture of a rib depends upon the presence of two classes of symptoms. 1. Those due to the fracture proper, such as pain, crepitus, false point of motion, and deformity. 2. Those clue to injury of the intrathoracic viscera. I. Signs Due to the Fracture Proper. — These are not as easily ehcited in the ribs as in the long bones, nor is it necessary to obtain all of them in order to make a diagnosis. Crepitus can rarely be elicited and no great stress should be placed upon its absence. It can be obtained at times by placing the hand over the suspected point of fracture and asldng the patient to breathe deeply. If this does not eHcit it, no further effort should be made to obtain it. Occasionally it may be heard with the aid of a stethoscope. A false point of motion may often be obtained by direct palpation over the seat of fracture without causing pain to the patient. Each rib should be examined by palpating it from its anterior to posterior ends for this 13 193 194 ' THORAX. sign. One must not mistake the apparent yielding of the lower ribs for this sign. During the same manipulation one can usually feel a depression or unevenness in the outline of the ribs if present. The latter is especially true in fractures at the costochondral junction. On placing one hand in front and the other at the back of the chest and compressing the chest, the patient will experience a sharp pain at the seat of fracture. The diagnosis must at times be made from the presence of pain and deformity alone, with or without accompanying symptoms of intrathoracic complications. 2. Signs Due to Injury of the Intrathoracic Viscera (i. e., of the Pleura or Lung. — These are discussed on page 196. They are friction rub, hemothorax, pneumothorax, emphysema of the subcu- taneous tissuse, hemoptysis and pneumonia. FRACTURES OF THE COSTAL CARTILAGES. Fractures of the costal cartilages themselves are most common in old age when they are ossified, while in younger persons there is a sepa- ration of the cartilage from the ribs. The diagnosis may be made from palpation of the deformity, the cartilage itself being displaced backward, while the rib is pushed out or forward. There is also local pain and some degree of abnormal motion. FRACTURES OF THE STERNUM. Aside from gunshot wounds, these are usually transverse and occur in connection with injuries of the spine as the result of crushing in- juries of the thorax. They are most common at the junction of the manubrium and gladiolus, and next most frequent opposite the third and fourth ribs. The diagnosis may be made from the severe pain referred to the site of the injury and the deformity. The defor- mity may be present either as a decided displacement backward of the manubrium, so that when the finger is passed along the sternum from above downward there is a sudden, sharp, step-hke elevation at the manubrio-gladiolar junction. In other cases there is a marked increase of the normal ridge or angle (angulus Ludovici) which these two portions of the sternum form with each other. Fractures of the sternum may be accompanied by signs of severe intrathoracic injury. Fig. 126. — Illustration of a Case of Traumatic Asphyxia (see text) Following Com- pression OF the Thorax. (Kindly lent by Drs. H. H. A. Beach and Farrar Cobb, of Boston, from their article in the April, 1904, purnber of the " Annals of Surgery.") INJURIES OF THORACIC VISCERA. 195 Injuries of the Thoracic Viscera. These may be divided into two classes: 1. The non-penetrating or subcutaneous. 2. Penetrating. The first group includes those following the application of a crushing force, whether appHed in a circumscribed manner, such as follows a blow or a fall upon some object, as well as in those where the force acts diffusely, e. g., crushing between two objects, etc. The second group includes those following the use of sharp or cutting weapons or the use of firearms of whatever nature. Lung- Right Lungr D ml Fig. 127. — Cross-section of Thorax (Diagrammatic) to Show Mode of Proddction of Pneumothorax OR Hemothorax and of Subcutaneous Emphysema as a Result of Fractures of the Ribs. ID, The arrow accompanying these letters shows the mode of action of indirect force in producing frac- ture of the ribs; D, mode of action of direct force in producing fracture of the ribs; P, pneumothorax as a re- sult of fracture of the rib and laceration of the pleura on right side; A, extensive subcutaneous emphysema as a result of puncture of a lung by the sharp ends of a fractured rib fragment; the triple arrow shows the mode of egress of the air from the punctured lung into the subcutaneous tissues; H, cross-section of heart; C, fracture at costo-chondral junction without displacement. I. NON-PENETRATING OR SUBCUTANEOUS. The thorax behaves like the skull toward a crushing force, but pos- sesses^ greater elasticity, so that its contents can alter their volume and form more readily. Death may follow immediately with symptoms of collapse without even visible external signs, probably as the result of the injury of the 196 THOR.\X. vagi. Serious injuries are more frequent after crushing of the thorax in younger persons than in older, because the elasticity of the ribs is greater and the ribs offer less resistance. The majority of injuries of this group are accompanied by fractures of the ribs and sternum. Traumatic Asphyxia. — This is a pecuhar result of severe thoracic compression (see Fig. 126). It may be recognized by the marked cyanotic discoloration of the head, face, and neck. This cyanosis terminates ver}^ abruptly in the upper portion of the thorax. It is usually accompanied by fractures of the ribs and emphy- sema. It is due to a dilatation of the cutaneous capillaries of the dis- colored parts. Subcutaneous Injuries of the Lungs and Pleura. — The diagnosis of these complications occurring either with or T\dthout fractures of the ribs depends on the appearance of the signs of pneumothorax or hemothorax, hemopericardium, pleuritis, emphysema of the subcu- taneous tissues, and hemoptysis. (a) Subcutaneous Injury of the Pleura. — A moderate degree of em- physema, or of pneumothorax vv^hich does not increase, or the presence of a dry pleuritic friction rub is indic- ative of an injury of the pleura. If the intercostal or internal mammar}' arteries are injured, there are evidences of hemothorax. One can make a probable diagnosis of pleural injur}^ alone from the presence of a slight degree of emphysema and of pneumothorax which rapidly subsides or from the friction sound alone. At times, injuries of the pleura wiU cause no symptoms. The emphysema can be recog- nized by the peculiar crackling or crepitating sensation obtained upon palpating the skin. (b) Subcutaneous Injury of the Lungs. — Subcutaneous injuries of the lungs cause a high degree of emphysema of the skin which rapidly spreads over the entire body (see Fig. loi) and may imperil life. In addition, a pneumothorax results which increases rapidly in degree, Fig. 128. — Emphysema of Skix Follouts-o Fractuile oe the Ribs on the Right Side. Note the puffiness of the face — the eyes ahnost closed (Warren). NON-PENETRATING OR SUBCUTANEOUS, 197 crowding the lung and heart over to the opposite side. Rarely it may become bilateral. Hemothorax and hemoptysis are also characteristic of subcuta- neous lung injury, varying according to the extent of the same and disappearing gradually. All of these signs of lung injury may be absent. Bloody sputum is especially apt to be inconstant. A number of cases have been re- corded where a pneumonia developed after a subcutaneous injury. Displaced lung. Ileum Lower sur- face of diaphragm Intestine passing through aperture in dia- phragm Fig. 129. — View of Diaphragmatic Herma niiii Diaphragm Raised in Order to show Hernial Open- ing IN Direction of Arrow. It was quite locahzed, but having all of the clinical characteristics of this disease. A pulmonary hernia may appear in one of the intercostal spaces as a reducible swelhng with a tympanitic note, becoming prominent on expiratory efforts such as coughing. It crepitates distinctly like lung tissue while being reduced. (c) Subcutaneous Injuries of the Diaphragm. — These are seldom recognized during life, being usually immediately fatal. They show 198 THORAX. marked displacement fsee Figs. 129 and 130; of the thoracic viscera by the abdominal organs which have escaped through the rent in the diaphragm. There is usually great dyspnea, cyanosis, and a distur- bance of cardiac action. In addition, there is a t}T3ipanitic note on percussion, bulging of the thorax, and gurghng on the injured side. A^omiting and symptoms of strangulation may also be present. In this connection it is well to speak of the frequent association of serious abdominal injuries, especially of the parenchymatous organs, with Displaced right lung ^_A^ Transverse colon Coils of ileum in thorax Diaphragm Small intestine Cecum Fig. 130. — Another View of Di.ajhr-agmatic Hernia shown in Fig. 129 with Dl\phr.^gm in Posi- tion AS Found at Autopsy. crushing injuries of the bony wall of the thorax or of the thoracic viscera. This association should always be borne in mind in the examination of such a case. (d) Subcutaneous Injuries oj the Pericardium, Heart, Blood-vessels, Esophagus, and Thoracic Duct. — With the exception of those of the pericardium, these injuries are so rare and rapidly fatal that they cannot be recognized during hfe. Injuries of the pericardium without external signs cause either a dry pericarditis or hemopericardium, PENETRATING INJURIES OF THE THORAX PROPER. 1 99 with the characteristic friction rub of the former and the increased area of dulhiess and other physical signs of the latter. In addition, there are always syncope and symptoms of collapse. Ruptures of the thoracic portion of the esophagus are very rare and can only be recognized by the resultant mediastinitis. There are nine cases of rupture of the thoracic duct recorded, of which eight were followed by chylothorax. 2. PENETRATING INJURIES OF THE THORAX PROPER. These may be due to the action of a sharp or cutting weapon or to gunshot wounds, and include chiefly injuries of the lungs and pleurae. As in the subcutaneous injuries, the cardinal symptoms are emphy- sema, pneumothorax, and hemothorax. All of these may, however, be absent. Pneumothorax. — This can be recognized by the usual signs, viz., a tympanitic note on percussion, the absence of respiratory and voice sounds and of vocal fremitus. If it is present upon the left side, there is displacement of the heart to the right. If the pneumothorax is only moderate in extent and disappears rapidly, it indicates pleural perforation alone (Fig. 127) and is due to the entrance of air through the wounds. If it increases and becomes more tense in spite of the external wound being closed, it indicates a wound of the lung which has remained open. Hemothorax. — In every case one must decide whether the hemor- rhage has occurred from the vessels of the thoracic wall (intercostal and internal mammary arteries) or from the lungs. {a) If from the parietes, the external wound is situated over the in- ternal mammary artery, if the hemorrhage is from this artery. If it is from the intercostal vessels, there is also an external wound to be found bearing some relation to these vessels. In both instances the diagnostic signs are the escape of blood from the wound in many cases, and the presence of a hemothorax. (&) If the hemorrhage is from the lung, there is expectoration of foamy blood and the signs of hemothorax. If the lung is adherent to the chest wall, foamy blood escapes from the wound. Hemoptysis may be absent if the bronchus is plugged or there is no communication of the wound in the lung with a bronchus. Bilateral hemothorax is usually fatal. Pneumothorax is often combined with hemothorax so that there is a combination of physical 200 THOEAX, signs of the presence of both air and Hquid in the chest, because the blood almost invariably remains liquid. 3. Emphysema of the Skin. — {a) If due to a pleural wound alone, it is only moderate in extent, and is due to the entrance of air through the wound and disappears rapidly. (5) If it be due to injury of the lung, it is far more marked and constantly increases. If the lung is adherent it may become excessive and cause death from asphyxia unless relief is obtained by artificially producing a collapse of the lung. 4. Dyspnea and Cyanosis. — These are only marked if there is a high degree of pneumothorax or hemothorax. 5. Prolapse of lung through the external wound is positive proof of a pleural injury. It is more marked during coughing or expiration. 6. The secondary comphcations of pleural and pulmonary injuries are pneumonia and empyema. These are more frequent after pene- trating than non-penetrating injuries. The hemorrhagic infiltration of the lungs favors the localization of microorganisms, especially of the pneumococcus. Penetrating Injuries of the Heart and Pericardium.— Just as in the case of similar injuries of the thoracic cavity proper and of the abdominal cavity, it is impossible to make a diagnosis of the perfora- tion of a viscus, from the position of the external wound alone, although its location over a viscus is of some value. The wound may be at some distance from the heart, as in gunshot wounds. In the case of injuries of the heart we place more value upon the accompanying general and local signs. In the majority of cases there is unconsciousness immediatelv after the accident, probably due to shock, since the same symptoms ap- pear after injuries of the heart without external wound. Accompanying this primary syncope, and especially to be noticed after consciousness has been restored, are the symptoms of collapse due to internal hem- orrhage. The pulse is very feeble and irregular; at times it is scarcely to be felt. There is marked anemia. The local signs of value in diag- nosis are those of the accompanying hemopericardium and pneumo- pericardium. In general, one may speak of three classes of cases : {a) Those associated with ■ a wound in the lung. In these the prominent symptom is pneumopericardium. This may or may not be associated with hemothorax or pneumothorax. The heart sounds are to be heard as if at a distance and there is a tympanitic note replacing the normal area of cardiac dullness. If there is a hemothorax there are signs of internal hemorrhage and dullness over the lung. In such INFLAMMATORY PROCESSES OF THE THORACIC WALL. 20I cases there is considerable anemia, marked collapse, and feeble pulse. (b) Those of the heart alone with escape of blood into the pericar- dial cavity. These give rise to all of the physical signs of hemopericar- dium, accompanied by very feeble and irregular pulse, cyanosis, dyspnea, and moderate anemia. The area of cardiac dullness is increased and one hears a splashing sound due to the heart beating in the fluid which surrounds and interferes with its action. This splashing gradually disappears as the pericardial cavity fills up. (c) This third class of cases is characterized by the escape of blood externally through the wound in the chest wall. The blood will be red or blue according to whether the wound is in the right or left heart. ^ In these cases there are marked collapse, signs of hemorrhage (pallor, rapid, very feeble pulse), and irregular heart's action. There is also a slight increase in cardiac dullness and no hemothorax. The diagnosis of whether the heart has been penetrated or not may be made from considering the location of the wound, the general symptoms, and the physical signs of pneumopericardium or hemoperi- cardium associated or not with those of pneumothorax or hemothorax. Penetrating Wounds of the Diaphragm. — These are usually associated with gunshot or stab wounds of the thorax and abdomen, and a diagnosis cannot be made until the wound has been explored. Acute and Chronic Inflammatory Processes of the Tho- racic Wall. of the skin and subcutaneous tissues. Furuncles are apt to appear on the back of the chest, and may become quite large, especially over the scapulae, forming large carbun- cles which extend quite deeply in the subcutaneous tissues. One must always bear in mind the possibility of diabetes in patients who suffer from these large or recurrent carbuncles. Acute phlegmon of the subcutaneous tissue of the thoracic wall is quite rare. It may occur by extension from suppuration of the axillary lymph-nodes. The infection travels rapidly in the connective tissue lying between the skin and pectoralis major muscle and in that lying beneath the latter. There is general tenderness, induration, and redness, accompanied by signs of septicemia. Tertiary Syphilis. — One of the favorite scats of gummatous ulcera- tions is on the skin of the back. They can be recognized by their irregu- 'Niebert: "Philadelphia Medical Jour.," Mar. 3, 1902. 202 THORAX. lar serpentine form, clear-cut, sharp edges, and deep character. Their multiple occurrence, lack of induration, and the absence of indurated lymph-nodes or lymph-vessels will exclude a carcinoma (see Fig. 131). Actinomycosis of the skin and subcutaneous tissue of the thorax is secondary to that of the lungs or mammary glands. In the former case one finds indefinite symptoms of pulmonary consolidation, with subsequent breaking dowm of lung tissue associated with multiple areas of softening and sinus formation in the skin. In that secondary to actinomycosis of the breast there are also sinuses of long duration leading to the parenchyma and discharging pus. The condition greatly resembles tuber- culosis, but there is a more brawny infiltra- tion of the skin, and ex- amination of the pus shows the actinomyces. Both sarcoma and car- cinoma of the skin of the thorax may occur as primary affections upon the site of a previous pigmented mole (see Fig. 132). AFFECTIONS OF THE BONY THORAX. Acute Osteomyeli- tis of the Ribs.— This is a very rare affection of the ribs, especially the form which is due to the organisms producing the same condition elsewhere, viz., the staphylo- cocci. It may occur as a complication of an acute infectious disease, such as influenza, pneumonia, and typhoid, either during the course of the dis- ease or following it. It is most frequent at or near the costochondral junction. In tlie form which follows the above acute infections the diag- nosis may be made from the history of the infectious disease, the local findings, and the constitutional disturbances. These two latter are swelling, acute pain, and tenderness over the rib, more or less fever, and leukocytosis. Fig. 131. — Tertiary Syphilitic Ulcerations of Back. Note the characteristic sharp edges and punched-out condition of the ulcers, and the tendency to oval outline. AFFECTIONS OF THE BONY THORAX. 203 Acute Osteomyelitis of the Sternum. — This condition is very rare, only nine cases having been reported. The symptoms are those of violent epigastric pain, high fever, delirium, and local inflammatory symptoms, such as tenderness and edema. The pus may collect in the an- terior mediastinum, which is the direction of least resistance; if so, the condition is very apt to be overlooked. Tuberculosis of the Ribs or Sternum. — This form of bone disease is comparatively frequent in the ribs and ster- num. Its course is so insidious that the patients often seek sur- gical advice onlv when a tubercular # CL '^ Fig. 133. — Lateral View of Patient shown in ^FiG. 132, WITH Primary Carcinoma of the Srin (J). The dotted lines {CL) indicate the nodules of a carcinomatous lymphangitis passing toward the axillary lymph-nodes which could be distinctly felt through the skin. Fig 132. — Primary Carcinoma of the Skin of the Thorax (T); CL, Carcinomatous Lymphan- gitis, THE Nodules of which Could be Dis- tinctly Palpated through the Skin. abscess or sinus has formed. It may at times be difficult to determine the point of origin of a tubercular ab- scess, owing to the fact that it is apt to gravitate so that its external open- ing is found at some distance from the original focus. Upon the back such an abscess may lie beneath the fascia and greatly resemble a lipoma (see Figs. 134 and 135), fluctuation being very indistinct. In the scap- ular region tuberculous abscesses both from the posterior ends of the ribs and from the dorsal vertebrae may appear gradually without any inflammatory symptoms or pain. The following are, in general, the diagnostic features of tubercular af- fections of the ribs and sternum. The appearance of a thickening of the rib or sternum is accompanied by slight pain and by elevation of 204 THORAX, temperature. In the more advanced stage, in which the cases are usually seen, a soft, fluctuating swelling is found, devoid of inflammatory symp- toms and distributed over one or several ribs and their interspaces. Such tubercular abscesses must be differentiated from lipomata and subcutaneous abscesses due to a spontaneously perforated empyema (see page 212). Lipomata are generally lobulated, the skin can be moved over them, and they are freely mov- able as a whole upon the thorax. They do not fluctuate. An abscess result- ing from a spontan- eously perforated em- pyema occurs oftenest in children and usu- ally around the nipple, but may take place anywhere. There is fever and the physical signs of an effusion in- to the pleural cavity (see Fig. 141). When single or multiple sinuses have formed, the diagnosis presents no difflcul- ties. There is a his- tory of a long- contin- ued, almost painless illness, with constant discharge of a thin yellowish pus. The edges of the sinus are hned by flabby or even caseous granulations. Tubercular abscesses may form upon the inner side of the rib as peripleuritic abscesses or collections of pus, and be difficult to differen- tiate from encapsulated empyema except from the history of an acute infection with high temperature. In elderly people a tuberculosis of the rib may begin as a marked enlargement and induration of the rib which greatly resembles a malig- nant growth until softening with accompanying fluctuation occurs. If tuberculosis occurs in the sternum and causes a retrosternal Fig. 134. — Direct Posterior View of Patient shown in Fig. 13s, showing the extent of the tumor, due to a tuber- CULOUS Abscess, Secondary to Dorsal Spondylitis, and Simulating a Lipoma. AFFECTIONS OF THE BONY THORAX. 205 collection of pus, the pressure symptoms may resemble those of a retrosternal tumor (see page 220) or of an aneurysm, but there is often an edema over the sternum. The pus generally escapes at the left of the sternum at the level of the second rib, but may gravitate downward toward the recti muscles of the abdomen. Syphilis. — The form of syphilis of the bones of the thorax that is of greatest interest is the gumma. It occurs as a flat, often exquisitely sensitive, localized thickening of the peri- osteum of the ribs and sternum greatly re- sembling the softer varieties of the peri- osteal sarcoma. When the process has affect- ed the bone itself, ne- crosis results and a sinus is present in the skin from which a ten- acious and homogen- eous pus escapes. At this stage it may be thought to be tuber- culosis. In the latter, there is generally a softer fluctuating swelling preceding the formation of the sinus. The pus from a tuber- cular abscess is cas- eous and flocculent and the granulations are flabby and often cheesy. There is also an absence of the history and of the manifestations of syphilis elsewhere. The latter is also true of those periosteal gummata resembling sarcoma of the ribs or sternum, i. e., before they are broken down. They also present more inflamma- tory symptoms, such as tenderness, etc., than a sarcoma, are slower in growth, and rapidly respond to antisyphilitic treatment. Fig. 135. — Lateral View of Patient as shown in Fig. 134, Suffering from Tubercular Abscess of Scapular Region, Simulating a Lipoma. The dotted line shows the extent of the pseudo-fluctuation. 2o6 THORAX. TUMORS OF THE CHEST WALL. In making a diagnosis of a thoracic swelling which can be either seen or felt externally the follo^^ing points must be considered: 1. How long has the swelling existed? 2. Does it belong (a) to the skin or the bony thorax, or (h) arise from within the chest and protrude externally ? 3. The consistency and other characteristics, such as rate of growth, etc. The various forms of tumors or swellings which occur are: I. From THE Skix Itself. 2. From the Boxy Thoe_a.x. Pigmented moles. Enchondromata of the ribs or sternum. Single or multiple soft fibromata. Sarcomata of the ribs or sternum. Sarcoma and carcinoma. Secondary carcinomata of the ribs or Capillary and cavernous hemangio- sternum. mata. Abscesses due to tuberculous ribs or ster- Lymphangiomata (capillary and cystic). num. Lipomata. Gummata of the ribs. 3. From within the Thor.a^:. Aneur3'sms. . Gravitation abscesses due to dorsal spondylitis. Spontaneously perforated empyemata. Actinomycotic abscesses. The characteristics of the swellings due to tubercular, syphilitic, or actinomycotic infection were considered on pages 203 and 205. All of the tumors in the above lists except the angiomata appear after birth. The tymphangiomata and hemangiomata do not differ from the same forms of new-growths elsewhere and have been fully de- scribed in the preceding chapter. They may at times attain an enor- mous size, involving the entire one-half of the thorax. Pigmented moles can be recognized by their bro^A^lish color and occurrence in the skin. They are stationary' in growth until a sarcoma- tous or carcinomatous change, when they increase in size rapidly, forming very malignant growths (see Fig. 132). Fibromata also occur in the skin^ eithei- as a single pedunculated, often very large tumor, or as multiple fibroma molluscum, smaller tumors (see Figs. 376, 377). They are, as a rule, quite soft, and slow in growth unless a sarcomatous change occurs. Sarcoma of the skin is not frequent. It can be recognized by its rapid growth and firmer consistency than ordinary fibromata. Lipomata almost always occur in the subcutaneous tissues of the back and sides of the chest. The skin is movable over them and the TUMORS OF THE CHEST WALL. 20"; tumors sho^Y characteristic lobulation. When deeply situated they may give rise to a sense of pseudo-fluctuation resembling that of an abscess. They may grow rapidly at times, giving rise to very large tumors. The most frequent tumors of the bony thorax are periosteal sar- comata of the ribs. Sarcomata of the sternum are much rarer. Sarcomata can be recognized by the history of a rapid growth, by their attachment to the ribs, and their firm consistency. They may at times spread over the inter- spaces to adjacent ribs (Fig. 136). They are seldom attached to the skin, which is usually freely movable over them. Pure enchondroma- ta of the ribs are infre- quent, but chondrosar- comata are almost as fre- quent as the pure perios- teal variety of sarcoma. They give rise to large and very firm tumors, which enlarge the rib rapidly in all directions. They may grow into the spinal canal and com- press the spinal cord. Secondary tumors of the ribs or sternum belong either to the car- cinomata or sarcomata. The diagnosis may be made from the sudden appearance of a growtli whose consistency varies according to the nature of the primary growth. This latter should always be searched for in such cases. Of swelhngs or tumors arising from within the thorax, the ones of chief interest are aneurysms and pulmonary hernia. The former can be recognized by the appearance of a prominence over the upper portion of the sternum (see Figs. 138 and 139) or over the second rib which pulsates in the expansile manner characteristic of aneurysms in general, and produces a distinct murmur on auscultation. They must be Fig. 136. — Periosteal Sarcoma Invol\ing Fourth, Fipth, Sixth, Seventh, and Eighth Ribs. The arrow points to the prominence caused by the tumor when viewed in an antero-posterior direction. THORAX. differentiated from those rare abscesses of tlie sternum or rib which have a transmitted pulsation. Their characteristic situation, the presence of murmurs, expansile pulsation, and the confirmatory A;-ray examination render a diagnosis easy in the majority of cases. A pulmonar}' hernia may appear as an oval swelling in an inter- space following a history of injury. It becomes more prominent on coughing, but can be reduced, giving rise to a crackling sound or crepitation. Quite rarely in- terthoracic lipomata penetrate the chest wall and appear ex- ternallv. EMPYEMA. Pus in the pleural cavity may be due to a number of causes. Causes.- — (a) It may fol- low pneumonia. It is then due to the pneumococcus, and is called a metapneumonic em- pyema. (b) It may occur secondary to other joci oj suppuration 0} the lung or neighboring viscera. This form is caused by the Streptococcus pyogenes. The infection extends to the pleura either by direct continuity of tissue or by means of the lymphatics. It is in one of these ways that empyema follows an abscess or gangrene of the lung, a subphrenic or hepatic abscess, an appendicitis, a perforation of the esophagus, or a penetrating wound of the thorax. The Strepto- coccus is often associated with the Staphylococcus aureus. These two, or other organisms such as the typhoid or colon bacillus, may cause an empyema independently. (c) Tuberculous Empyema.— This is a ^-ariety which is due to the tubercle bacillus, either alone or in conjunction with streptococci or staphylococci. The diagnosis of empyema may be from : 1. The histor}'. 2. The chnical course. Fig. 137.- — Capillary Angioha of ^LAiniAHY Region OF Infakt. EMPYEMA. 209 3. The physical examination and resuhs of exploratory puncture. History. — There is either an accompanying pneumonia, or the his- tory may show that it followed a preceding pneumonia or serofibrinous pleurisy or one of the acute infectious diseases, hke typhoid, measles, scarlatina, etc. It may also follow some septic pulmonary or abdomi- nal process or there may be the history of a trauma. There often may be a coexisting pulmonary tuberculosis. Clinical Course. — The symptoms may have appeared in a slow, insidious, or in an abrupt manner. In the former there is gradually increasing pallor and emacia- tion. In the acute onset the disease begins with a chill and great prostration. After the disease has begun there is a fever of a continuous type in the ordinary purulent form and of an irregular type in the putrid empyemata. In the latter there are frequent chills and remissions of tem- perature. There is marked leukocytosis. Repeated pro- fuse sweats are quite charac- teristic. Physical Examination (see Figs. 140 and 141). — Inspec- tion shows diminished move- ment on the side of the effu- sion. In children there is often bulging of the intercostal spaces. In left-sided empyema the apex-beat is seen to be displaced to the right beyond the right sternal •line. In children there is often a lateral cur^•e of the dorsal spine, the convexity being toward the diseased side. Palpation. — There is absence of vocal fremitus except in children, where the transmission of the voice sounds is frequently retained. The apex-beat can be felt to be displaced a variable distance to the right in a left-sided empyema. Percussion. — If the exudate Kes between the two adjacent lobes of a lung (interlobar), or between the base of a lung and the diaphragm (diaphragmatic form), it cannot be recognized by percussion. The 14 Fig. 138. — Side View of Case of Aneurysm of the Arch of the Aorta. 2IO THORAX. area of dullness, or rather flatness (the note being of a wooden quality), may be circumscribed (Fig. 142) or diffuse, according to whether the empyema is encapsulated or not. In the diffuse variety the upper line of dullness is either S-shaped or flat. The liver and spleen are dis- placed downward. Auscultation. — Over the area of dullness the breath and voice sounds are absent, while above it they are harsh and exaggerated. In children both of these signs are apt to be misleading because the respiratory murmur and voice sounds are often increased, even tubular in quality. Exploratory Puncture. — This method is of great value. The needle should be of medium length and about twice the caliber of an ordinary hypodermic needle. It should be inserted into the center of the area of dullness in an encapsulated empyema. In the diffuse variety it is best introduced in the sixth inter- space in the midaxillary or postaxillary line and the pis- ton gradually withdrawn. If the examination is seen to be negative when the piston has been withdrawn one-third of the way, the needle should be pulled out. One will often find a drop of pus in the tip of the needle when none has been drawn into the barrel of the syringe (Fig. 143). Differential Diagnosis of Empyema. — {a) From Pneumonia. — The onset of pneumonia is always . sudden, accompanied by a chill, the fever is higher, there is more cyanosis and dyspnea, and the sputum is rusty. The dullness is not so wooden in character, there is less resis- tance, and vocal fremitus is not absent. In some cases the auscultatory signs, especially in children, may be very confusing. In such patients the voice and respiratory sounds are either plainly to be heard or are even exaggerated. The only way in which such cases, in both adults and children, can be differentiated from empyema is by exploratory puncture. Fig. 139. — Front View op Same Case shown in Fig. EMPYEMA. 211 Fig. 140. — Area op Flatness in Left-sided Diffuse, that is, Non-encapsulated, Empyema. A, Location of apex-beat. The dotted area above it indicates the area of dullness of the displaced heart. The numerals refer to the respective ribs. The same holds true for cases of circumscribed dulhiess in children due to slowly resolving bronchopneumonia with persistent fever, pallor, and sweats. (b) From Tumors and Hydatids of the Lung and Pleura. — Both of these give rise to dullness with sup- pression of respiratory sounds. The percus- sion note is, however, even flatter than in empyema and there is greater resistance. There is also no fever or sweats and an ex- udate, if present as the result of the tumor, is hemorrhagic in char- acter. (c) Hepatic and Right-sided Subphrenic Abscesses. — These give rise to dulhiess and ab- sence of voice and res- piratory sounds in the lower portion of the pleural cavity. The area of dulhiess is, however, quite local- ized (see Fig. 163) or does not extend very high. There is a his- tory of preceding ab- dominal infection and the liver is displaced dovniward far more than is the case in an Fig. 141.— Area of Flatness in a Case of Diffuse, that is, Non- empyema, i lie SCptlC encapsulated. Empyema OF THE Right Pleural Cavity SVmptOmS are alsO L, Area of liver dullness, merging above into the flatness of the empyema. 1 1 -1-1 The ribs are indicated on the left side by numerals. USUaliy mOrC marKCQ. 212 THORAX. The pus from a heptic abscess is chocolate colored; that from an empyema, yelloAA'. In left-sided subphrenic abscesses the dullness is often most marked at the back of the chest. An empyema may spontaneously rupture through the pleura and form a subcutaneous fluctuating tumor (see page 204) from the third to the sixth interspace, usually the fifth. When near the heart the tumor may pulsate. On the other hand, the pus may escape along the peripleuritic connective tissue and gravitate toward the abdominal or lumbar muscles, appearing as an abscess in these regions, simulating one following disease of the spine or a perinephritic abscess. Fig. 142. — Location of Flttid ix Diffuse axd Ekcapsulated Thoracic Empyzmata, as seen k Cross- section (DiAGRAililATIc). DE. The black area represents the distribution of the pus in a diffuse empyema; CE, black area represents the distribution of the pus in an encapsulated empyema; H, cross-section of heart; RL, right lung; LL, left limg (compressed) TUMORS OF THE PLEURA. Carcinoma, en chondroma, endothelioma, and rarely lipomata are obsen^ed in the pleura. The carcinomata and sarcomata are almost always secondary to the same growths in the ribs, mammary glands, mediastinal hmiph-nodes, and lungs. The hpomata may arise from the mediastinal or subpleural fat and project into the pleural cavity. The diagnosis of tumors of the pleura is very difficuh, unless there is demonstrable primary tumor. The s}-mptoms simulate those of a pleural or pericardial effusion, and they are frequently accompanied by more or less exudate, which is hemorrhagic in character, but may be serous. A tumor can be suspected if there is increased resistance when the needle is introduced and bv the absence of fever. In the mahg- PULMONARY ABSCESS, GANGRENE, AND BRONCHIECTASIS. 213 nant forms of pleural tumors there is rapidly increasing cachexia; the effusion, if present, reaccumulates rapidly; and there are often severe intercostal neuralgic pains due to the tumor growing through the intervertebral foramina. PULMONARY ABSCESS, GANGRENE, AND BRONCHIECTASIS. The lesions that present themselves for diagnosis may be classified as follows: (a) Acute simple abscesses; (b) chronic simple abscesses, / / Fig. 143. — Method of Performing Exploratory Puncture of the Pleural Cavities. After careful disinfection of the. area of skin through which the puncture is to be made, the needle should be inserted through either the sixth interspace in the anterior midaxillary or posterior axillary lines. This method can be carried out with the patient either Ij'ing down or sitting up, preferably the former. Before inserting the needle, the skin should be pressed against thc-tissues of the interspace, in order to prevent any slipping and striking of the bone with the point of the needle. with or without bronchiectasis; (c) acute gangrenous abscesses; and (d) chronic putrid abscesses, with bronchiectasis. As to the symp- tomatology of pulmonary abscess, the following is usually the history: A patient who has had pneumonia, for example, of the lower lobe will have his crisis, the physical signs begin to clear up, the temperature 214 THOEAX. drops, when suddenly the temperature goes up again, becomes of a remittent type, and the sputum becomes more purulent. There may be a distressing cough, accompanied by the expectoration of pus in large quantities. Some elastic fibers may be present in the sputum, but are rare. There are often paroxysms of coughing, with expecto- ration of several ounces to a cupful of pus. If the abscess cavities Fig. 144. — Method of Counting the Ribs for the Purpose of Determining the Level of Fluid, etc., LN THE Pleural Cavity. One usually begins by palpating the angulus Ludovici or prominence at the junction of the first and second portions of the sternum, that is, of the manubrium and gladiolus. By passing the fingers outward one strikes the second rib. From this point do\\Ti the remainder of the ribs can be readily counted. do not communicate with a bronchus, there is but little expectoration. There is in all cases emaciation, loss of appetite, and a rapid decline in strength. If the abscess becomes chronic, there may be recurrent attacks of fever, with a great deal of expectoration. Physical exami- nation is rather disappointing. There are few cases in which there are cavity signs present. This is due either to the indirect manner in which the abscess communicates with the bronchus, or to the fact that it Fig. 144 a. — Illustration of Pulmonary Gangrene Close to Surface of Pleura. Note the greenish color of the wall of the area of pulmonary gangrene and the trabeculas of surviving lung septa traversing the wall of the cavity. PULMONARY ABSCESS, GANGRENE, AND BRONCHIECTASIS. 21 5 does not open into one at all. The pulmonary lesions following pneumonia are most frequently in the lower lobes, and this is of some aid. There are no typical physical signs of abscess of the lung owing to the fact that the cavities (whether due to abscess, gangrene, or bronchiectasis) may be near the surface or quite deeply situated, and may or may not communicate with a bronchus. Dullness, decreased respiratory murmur, vocal resonance, and fremitus are present in the majority of cases, but there may be bronchial breathing. The most valuable sign is the presence of rales — large, moist ones, not infrequently metallic in character. Another striking feature is the variability of the physical signs— once dullness, then a tympanitic note over the same spot. A pus cavity, surrounded by aerated lung tissue and not communicating with a bronchus, gives no auscultatory phenomena. Clubbed fingers develop quite early, as do also pressure symptoms on the heart, liver, and spleen. If after a pneumonia the fever either does not disappear or begins again a few days after a crisis, and the sputum and breath become fetid, and the sputum divides itself into the characteristic three layers, gangrene must be suspected. This, as Frankel has shown, is a frequent sequel of influenza pneumonia. In the sputum of gan- grene one can usually find elastic fibers. In bronchiectasis following pneumonia the sputum may be fetid at times, but the odor is not so, penetrating and there are no elastic fibers. The physical signs of both pulmonary gangrene and bronchiectasis are usually the same as those of abscess. In a patient with bronchiectasis there is usually a history of long- continued expectoration, with the sudden expectoration of large quantities of pus, at times a cupful. This, however, is not characteristic, for the same may be true of chronic simple abscess. There is said to be more mucus in the sputum of a bronchiectasis, but if there are cavities in the lung tissue due to ulcerations of a bron- chiectasis there may be just as much pus as from a simple abscess and, if there is associated gangrene, just as much fetor as in a gangrene. The frequency of hemoptysis in cases of a gangrenous process is due to the fact that the vessels are more apt to pass exposed through the cavity, owing to the more rapid destruction of tissue. (a) The previous history of pneumonia, particularly an influenza pneum.onia, and (b) the character of the sputum — which in an abscess is of a chocolate color and occasionally contains elastic fiber, and in gaitgrene becomes more and more offensive as the case progresses — are important points in the estabhshment of a diagnosis. In bron- chiectasis the sputum is at first odorless, but usually becomes foul from the stagnant pus. The localization of the abscess is always 21 6 THOEAX. difficult; aspiration is dangerous, the physical signs are not reliable and are often misleading. The x-Y&y is only of confirmator}' value, as it shows chiefly thickened areas of lung, and should not be absolutely relied upon. When it shows a shadow at the same point where the physical signs are present, it is of value. The latter may mislead one as to the seat of the abscess, and is of no service in distinguishing between single and multiple foci. ECHINOCOCCUS OF THE LUNGS. This localization of the echinococcus is next in frequency to that of the liver and occurs oftenest in the right lower lobe. Chnically it greatly resembles a pleuritic effusion, and a diiferential diagnosis can be made only by examination of the fluid obtained by explorator}'' puncture. In the case of echinococcus it is clear, water}', and contains the characteristic hooklets of the worm. Only large cysts or a collection of smaller ones produce any symp- toms. These cause dullness which is more irregular than that of an effusion. There are signs of pressure, such as dyspnea, displace- ment of the heart and liver, pain, especially upon lying on the diseased side. There is often enlargement of the cutaneous veins over the cyst and widening of the intercostal spaces. There is no rise in temperature unless the cyst is infected and has ruptured. Then the signs greatly resemble those of a cavity in the lower lobes. ACTINOMYCOSIS OF THE LUNGS AND PLEURA. This disease may appear clinically in one of two forms: (a) A peribronchial pneumonic form in which the symptoms re- semble those of tuberculosis. The diagnosis can only be made if the ray fungus is found in the sputum. (b) A second cHnical form in which the disease has extended into the pleural ca\dty and chest wall. The signs are those of a pleurisy but without effusion, or there is a board-like infiltration of the chest wall followed by the appearance of subcutaneous abscesses. The spontaneous perforation of the latter leaves sinuses which may be confused with those of tuberculosis. The finding of the ray fungus will clear up the diagnosis. SUPPURATIVE PERICARDITIS. 217 Tumors of the Lungs. Tumors of the lungs are almost always malignant, and rarely primary. Secondary growths are usually disseminated over both lungs, while primary ones occupy the greater part of one lung. The diagnosis of the presence of secondary tumors depends upon (a) the appearance of pleuritic pain; (b) cyanosis; (c) dyspnea; (d) cough, and (e) the signs of effusion following a year or more after a primary tumor of the breast, limbs, etc., has been diagnosed as such. A primary growth of the lungs shows unilateral involvement with signs of consolidation, but the tactile fremitus is absent and the breath sounds are diminished in intensity. There is prune-juice expectoration, emaciation, and enlargement of the adjacent cervical lymph-nodes. Suppurative Pericarditis (Pyopericardium). Fluids, whether pus or serum, lying within the pericardial sac cause the same physical signs. Purulent pericarditis may (a) be pyemic in origin, or (b) follow a penetrating wound of the pericardium, or (c) arise by extension from a neighboring focus. Perforation of the thoracic wall may occur, giving rise to sinuses or abscesses. Purulent pericarditis occurring during the course of a septicopyemia cannot be recognized except from the physical signs, or if attention has been called to the heart by the accelerated, feeble, and often irregular pulse. In the other varieties there are usually repeated chills accompanied by high fever and sweats. The pulse and respiratory rate are rapid. Cases occasionally occur with normal pulse, temperature, and respira- tion. When an exudate previously serous becomes purulent, there are chills with considerable fluctuations of temperature, pulse, and respira- tion, accompanied by sweats, a rapid emaciation, and leukocytosis. The physical signs of pyopericardium are bulging of the precordial space, especially in children, the apex-beat cannot be felt, the area of cardiac dullness is greatly increased and pear-shaped, the base being downward, and the heart sounds are very weak. Exploratory puncture of the fourth and fifth left interspaces, one inch from the sternal margin, shows the presence of pus. The xipho- costal route is, however, used by many, the needle being inserted at 2l8 THORAX. the right xiphocostal angle. There is no danger of wounding the hver or diaphragm, because these are depressed in pyopericardium (Fig. 145)- Affections of the Mediastinum. Two conditions of this region frequently require to be recognized by the surgeon as well as by the physician. These are inflammatory affections and tumors. Fig. 145. — MzTHOD or Performing Exploratory Punxtcre of the Pericardium, in Order to Deter- mine THE NATURE OF A PERICARDIAL EXUDATE. The patient can be thus explored either in a recumbent or upright position. The needle should be inserted in either the fourth or fifth interspaces close to the sternum, great care being taken not to insert it too deeply. INFLAMMATORY PROCESSES. These may be either acute or chronic. The foiTiier are caused by the ordinar}^ pyogenic organisms and arise by extension of suppurative processes in the neck or rarely from an acute osteomyelitis of the ribs or sternum. From the neck, pus may reach the mediastinum either along the carotid sheath or along the previsceral or retrovisceral spaces. The symptoms of acute mediastinitis are severe pain and a feehng of oppression behind the sternum radiating to the shoulders. This is accompanied by fever, chills, sweats, rapid pulse, and other signs of TUMORS OF THE MEDIASTINUM. 219 a septic infection. The diagnosis may be made from tliese symptoms, taken in conjunction with the history of a preceding infection in the adjacent parts. Chronic ini3ammatory processes are ahnost always due to tuber- culous disease of the bronchial lymph-nodes and are impossible to recognize unless they rupture into the bronchus, aorta, or esophagus. TUMORS OF THE MEDIASTINUM. All tumors of the mediastinum cause somewhat similar symptoms. Their severity depends upon the size and nature of the growth. The most frequent conditions which thus appear with signs of intra- thoracic pressure are the following : Bknign Afpections. Malignant Affections. 1. Retrosternal goiter. i. Carcinomata. 2. Dermoid, cysts. 2. Sarcomata. 3. Echinococcus cysts. 3. Hodgkin's disease. 4. Aneurysms of the arch of the aorta. 5. Fibroma. The diagnosis in the case of the malignant affections depends (a) upon the greater rapidity with which the symptoms of pressure appear, (b) the more frequent association of pleuritic effusion, and (c) in many cases the history of primary growths situated elsewhere in the body. The symptoms in general of mediastinal tumors are: 1. Engorged veins on the anterior and lateral portions of the thorax, sometimes accompanied by cyanosis and edema of the skin (see Fig. 146). 2. A marked dyspnea, associated often with a harsh, brassy cough. 3. Symptoms of pressure on the recurrent laryngeal nerves cause abductor paralysis of one or both vocal cords, usually the left. 4. Dysphagia through pressure on the esophagus. 5. Dullness over the upper portion of the sternum or adjacent portion of the thorax (Fig. 146). 6. In some cases the x-yslj shows a distinct shadow. 7. The heart and lungs may be displaced. 8. There may be a bulging which may or may not pulsate. If it does, it has the forcible expansile pulsation of an aneurysm (Fig. 138). 9. Palpation of the suprasternal notch and of the deep cervical nodes may confirm the suspicion of a tumor. When an aneurysm has not eroded the chest wall it may be almost impossible to differentiate it from a tumor. The cyanosis and venous enlargement are more marked in tumor and these symptoms are more 220 THORAX. progressive. The most valuable signs of aneurysm are the diastolic shock to be felt and often heard over the sac, and the radiating pains to the arms and neck. Dermoid or echinococcus cysts may occasionally be recognized by finding hairs or booklets respectively in the sputum. A case of der- moid cyst has been recently reported by Senn in which the diagnosis was made by finding hair in the sputum. Foreign Bodies in the Air Passages. The diagnosis of foreign bodies in the larynx, trachea, or bronchi depends (a) upon the history, (b) upon the appearance of certain symp- toms of disturbances in function, and (c) the results of examination with the r^f-ray, the lar3Tigoscope, and the bronchoscope (Fig. 91). In the majority of cases there is a history of the aspiration dur- ing an inspiratory effort of one of four varieties of foreign bodies. (a) Round or conical bodies — e. g., coins, buttons, tin whistles, and bullets. (b) Sharp bodies, as pins, needles, tacks, and splinters. (c) Vegetable substances which swell, such as seeds or beans. (d) Vegetable substances which do not swell, as wheat, .etc. The symptoms vary greatly. In some cases there are frequent attacks of asphyxia. Especially is this the case with the first class referred to and in the initial period. In other cases these attacks of suffocation may be absent. If the body lodges in the right bronchus, as is most often the case, there is a diminution or even complete loss of respiratory sounds and movements on the same side. Over the point Fig. 146. — Location of Area of Dullness in jVIediastinal Tumor AND OF Prominence in Aneurysm of the Ascending Arch OF THE Aorta. I, Area of dullness over manubrium in a case of sarcoma of the mediastinum. The outlines running toward it represent the dilated veins of the skin of the thorax. 2, This figure is placed to the left of the most frequent seat of prominence due to aneurysm of the ascending portion of the arch. INFLAMMATORY PROCESSES. 221 of its arrest sibilant and sonorous rales may be heard. Sharp bodies at times cause localized pain, while larger obstructing bodies cause a sense of pressure. Cough is quite frequently present and the expec- toration may be bloody from erosion of the bronchi. After noting the history and the symptoms an examination should be conducted with the laryngoscope. If this results negatively an x'-ray picture is taken. If the latter is also negative the patient should be anesthetized and the Killian bronchoscope employed to find the loca- tion of the foreign body. In the absence of a history one must at times suspect the presence of a foreign body from the symp- toms of a circumscribed broncho- pneumonia or bronchiectasis or ab- scess formation without other causes. Diseases of the Breast, inflammatory processes. These may be of four varieties : (i) Acute puerperal mastitis, (2) acute mastitis of infants, (3) trau- matic mastitis, and (4) chronic mastitis. I. Acute Puerperal Mastitis. — This occurs most frequently during the first months of lactation. The acute inflammatory process may be located in one of three places (see Fig. 147) : (a) In the subcutaneous tissue of the areola. (b) In the gland parenchyma proper. (c) In the retromammary space. The diagnosis of the first named is simple. An area of redness and painful swelling of the areola occurs which is at first hard and then becomes soft. Infection of the gland proper, to which one usually refers in speaking of mastitis, most often follows a small painful fissure or crack in the nipple. Not infrequently the disease begins with a chill; a rise of temperature to 103° or 104°, and severe pain in the breast Fig. 147. — Seats of Various Forms of Suppura- tion IN Mastitis. I, In subcutaneous abscess of areola; 2, large parenchymatous abscess approaching surface of breast; 3, seat of suppuration in early stages of ordinary parenchymatous mastitis, showing how infection is transmitted from nipple along milk ducts; 4, retromammary abscess, lying between breast and pectoraHs major muscle; 6, cross-section of clavicle; 7, cross-section of first rib (modified from Duplay). 222 THORAX. in a woman in whom there is the history of a preceding fissure. The breast becomes extremely tender to the touch and the severe pain radiates toward the axilla. In the early stages there are distinctly indurated and usually multiple areas to be felt in the breast, which can be distinguished from the nodules due to stagna- tion of milk, or so-called "caking of the breast," by the more severe in- flammatory symptoms, such as pain, fever, etc. Another point of differentiation is the fact that massage and proper support will be followed by speedy dis- appearance of symp- toms in the "caked" breast, while in the true mastitis they persist and increase in severity. In puerperal masti- tis, in addition to the severe pain in the breast, induration, and rise of temperature, there is a painful en- largement of the pector- al and axillary lymph- nodes (Fig. 148). After a few days of the above symptoms the indurated areas become larger and approach the overlying skin. This becomes red and tender, and soon evidences of fluctuation can be obtained, showing that abscess formation has occurred. If after one of these foci has been opened the temperature persists, abscesses elsewhere must be present with retention of pus. Fig. 148. — Lymphatics of Female Breast. I, Carcinoma in outer upper quadrant; 2, supraclavicular lymph- nodes; 3, axillary lymph-nodes; 4, nodes along the lower border of pectoralis major; 5, nodes along the latissimus dorsi; 6, lymphatics of arm. The arrow between i and 3 shows the direction of the lymph-- current from the breast toward the axillary and supraclavicular nodes; the arrow between the breast and 4 shows the direction toward the corresponding nodes. The arrow from 6 to 3 sho\vs direction of lymph- current from arm infections toward the axillary nodes. INFLAMMATORY PROCESSES. 223 There are cases of puerperal mastitis in which a discharge of pus continues from muhiple foci months after the abscesses have been opened. These are the result of a venous congestion due to allowing the breast to sag by not being sufficiently compressed and supported. The retromammary form of acute mastitis is not frequent. It can be recognized by the absence of foci in the areola or parenchyma, although there is marked swelling along the periphery of the breast, accompanied by pain and high fever. Fluctuation appears at the lower margin. At times chronic retromammary ab- scesses are met with, due in the majority of cases to tu- berculosis of the ribs. 2. Mastitis Neona- torum. — During the sec- ond to fourth week painful enlargement of the breast occurs in both male and female infants. The breast enlarges to the size of a walnut, is quite hard and tender. This enlargement generally disappears with- in a short time, but may rarely go on to suppura- tion, giving rise to redness of the surface and fluctua- tion. 3. Traumatic Masti- tis. — After a blow or fall upon the breast of non- pregnant women the organ becomes enlarged, quite painful, and may be accompanied by slight rise of temperature. The diagnosis jnay be made from the history, the local tenderness, and the frequent general enlargement and palpation of tender indurated areas in the parenchyma. Chronic Mastitis. — This condition is one which has been de- scribed by various writers under different names. Koenig has called it "chronic cystic mastitis"; Reclus describes it as "maladie cystique"; Virchow, as "diffuse fibroma"; others have termed it "chronic inter- FiG. 149. — Method of Palpating a Tumor of the Breast (Cyst). 224 THORAX. stitial mastitis"; and, finally, the term "diffuse fibroadenoma" has been given to it. From a pathologic standpoint^ there are three types: 1 . A low grade of inflammation T\ath desquamation of the glandular epitheHum and the formation of cysts. This is the form described by Koenig as a chronic cystic mastitis. 2. Those of a more adenomatous t}'pe described by Schimmel- busch and Reclus. 3. Transition cases. In these the breast may show a dift"use fibro- adenomatous condition, but in certain areas a malignant change, i. e., to carcinoma, has taken place. In thirty cases ex- amined microscopically by Greenough^ such a malig- nant change had occurred in three. This condition occurs predominantly in women who have borne children, but not nursed them, and especially often just before the menopause. It may, however, occur in nulli- parae. In some cases there is an apparent exacerba- tion at the time of men- struation, new nodules ap- pearing and the breasts Fig. 150 — Palpation of Supraclavicular Lymph-nodes es? bcCOming painful, the COn- THE Female, in Case of Suspected Carcinoma of the ,.,. i • t • n B^j,As.j._ dition subsidmg rapidly m the menstrual inter^-als. Clinically, one can feel a number of flat leathery nodules in one or both breasts, which may be quite sensitive. The patients will often state that the nodules become painful during the menses, accompanied by an enlargement of the axillary and pectoral lymph-nodes (Figs. 150 and 151). If a cyst of any size (Fig. 149) is present, it feels tense and elastic. ' Curtis and Wood: "^Medical News," August 13, 1904. ^Greenough and Hartwell: "Journal of Medical Research," June, 1903. TUBERCULOSIS OF THE BREAST, 225 If a number of smaller cysts have been formed they feel hke beans or shot (Curtis). The principal affection from which it must be differen- tiated is carcinoma. This question is especially apt to arise if one or more large cysts have formed. The condition can be, however, distinguished from car- cinoma by the following features: 1. Chronic mastitis is usually bilateral, or if not, there are many nodules in a single breast which are frequently quite tender. 2. The nodules, if cystic, have a distinct smooth, rounded form, and unless very tense show fluctuation. 3. The size and ten- derness of the nodules often increase during menstruation. 4. The axillary nodes, if enlarged, are soft and tender. 5. The progress of the disease extends over years, unless large cysts are present. There are a few ex- ceptions; for example: 1. Cases in which there is marked indura- tion and sharp demarca- tion. Fig. 151. — Palpation of Axillary Glands in the Female. 2. Cases in which car- cinomatous changes have already occurred (transition cases), either in one of the breast nodules or in the axillary nodes alone. In such cases it is absolutely impossible to differentiate between a chronic cystic mastitis and carcinoma until marked retraction and fixation of the nipple and marked induration of the tumor and of the axillarv nodes have occurred. TUBERCULOSIS OF THE BREAST. Of 100 reported cases of this rare condition, only 65 have been examined microscopically. It involves the gland most frequently at 226 THOR.\X. the period of life (twenty to forty) of its greatest activity. The course is a very chronic one. It either occurs in (a) sl nodular form; (b) as a cold abscess; (c) confluent form fmost common); (d) miliar\\ The diagnosis is rarely made before either an abscess has formed or sinuses exist. Usu- ally the case is sup- posed to be a fibro- adenoma in the nodu- lar form or is diag- nosed as a chronic cystic mastitis (espec- ially in the more con- fluent form) before operation. Sinuses, if they exist, have the typical bluish under- mined edges of tuber- cular lesions. In every case the axillary lymph-nodes are enlarged, but if these are absent the diagnosis may be very difficult. Simple cysts re- sulting from chronic mastitis are more cir- cumscribed, fluctuate much sooner, are often painless, and do not enlarge the axillary nodes. When the cysts are small and tender, the dift"erentiation is very difficult. In tu- berculosis there is, however, early axillary lymph-node enlargement. From the scirrhus form of carcinoma this condition can be distin- guished by the fact that tuberculosis occurs in younger persons, is never as indurated, and there are more apt to be multiple nodules. From actinomycosis it can be distinguished by finding the ray fungus in the yellow granules and by the thickened indurated skin. Fig. 152. — Relation between Lyuphatics of Femaie Breast and THOSE OF iMEDIASTINClI AND LrTER. M, Carcinoma of breast, causing retraction of nipple; i, I\inph- nodes of supracla\'icular fossa; 2, cross-section of claWcle; 3, pectoralis major muscle; 5, lymph-nodes along the internal mammary artery; A, aorta; 4, hmph-nodes at bifurcation of trachea; these may cause dyspnea and cough after carcinoma of breast; H, heart, seen in section; 6, lymphatics of upper surface of liver, which receive the lymph from the mediastinal nodes through the diaphragm; 7, metastatic foci in the liver; 8, lymph-nodes at porta hepatis; 9, lymph-nodes, along aorta (modified from Kuttner and Duplay). BENIGN NEOPLASMS. 227 HYPERTROPHY OF THE BREASTS. This condition can be readily recognized, owing to the enormous bilateral increase in the size of the breasts. It occurs most often at puberty or shortly thereafter. It may be simulated by a retromammary lipoma, but this is only unilateral. The breast may increase so rapidly in size that within a year it increases ten to twenty pounds, or even more, in weight, and extends down as far as the knees. A hyperplasia of the male breast occurs on either one or both sides, and causes pain and dis- comfort. ^^M f NEOPLASMS OF THE BREAST. These are best divided into two great classes, the benign and the malignant. To the former belong the fibroadenoma, with its special forms, the fibroma intracanaliculare, and the papillary form. To the second or malignant group belong the sarcoma and carci noma. ' Fig. 153. — Retraction of Nipple in a Case of Carcinoma OF THE Breast. The arrow points downward toward the retracted nipple. BENIGN NEOPLASMS. Fibroadenoma of the Breast. — Pure fibromata and pure aden- omata are \'ery rare. The majority of these tumors contain both forms of tissue, but usually more of the fibrous than of the glandular. The chief diagnostic points are: (a) Age. They generally occur between twenty and thirty. (&) Growth. As a rule, the increase in size is very slow and gradual. In some cases they remain dormant for many years, and then suddenly increase in size. Apparent recurrence may lake place, but these are undoubtedlv new tumors. 228 THORAX, (c) Mobility, consistency, and form. They are usually quite firm and round, or oval. The larger they grow, the softer do they become. The nearer the skin they lie, the more movable are they. As a rule, they are not painful and are never as hard as a carcinoma. When removed, they are found to be distinctly encapsulated. (d) They never cause retraction of the nipple or enlargement of the axillary lymph-nodes. Even in the unusual pathologic forms of fibroma intracanaliculare, simple or papillary, the same clinical signs above described are retained. MALIGNANT NEOPLASMS. Sarcoma of the Breast. - — These constitute about 2 to 8 per cent, of all breast tumors and are usually of the round -celled type. They occur before the age of thirty, and are characterized by their rapid growth and the early ulceration of the overlying skin. The entire breast is usually involved, causing it to feel uniformly firm. En- largement of the axillary lymph-nodes is not frequent, but when present the secon- dary tumor attains enormous size. Carcinoma of the Breast. — The best division of this form of neo- plasm from a clinical point of view is into a scirrhus or hard, and a medul- lary or softer variety. Colloid carcinoma may occur, but is relatively rare and cannot be diagnosed as such before operation. The chief diagnostic points of carcinoma are: (a) Age. — The medullary form usually occurs in women between thirty-five and fifty-five, while the scirrhus variety occurs after the latter age. Carcinoma more frequently affects the breast of women who have nursed children, or have had infections or chronic cystic mastitis (page 223). There is undoubtedly a direct relation between cancer of the breast and trauma. Fig. 154. — Anterior View of Case of Sarcoma of the Breast. Note the enormous enlargement of the right breast (5), and the large tumor of the axilla (AL), due to secondary enlargement of the axillary lymph-nodes. MALIGNANT NEOPLASMS. 229 (b) Location and Groivth. — The disease usually begins as a single nodule, most frequently in the inner quadrants of the breast. If the carcinoma begins in the ducts instead of the acini, there is early fixation and induration around the nipple. This duct or tubular form of carcinoma is the one usually found in the male. It is less fre- quent than the deeper acinous form in the female breast. The carcinomatous nodule is usually single. The rate of growth is far more rapid than in the case of benign tumors. In the medullary form this is more marked than in the scirrhus. (c) Mobility, Consis- tency, and Form. — In the early stage the tumor is hard and somewhat mov- able. It soon becomes ad- herent to the skin (especi- ally around the nipple in the scirrhus form) and to the underlying pectoral muscle (Fig. 152). In the medullary form the tumor is much softer than in the scirrhus-form. Ulceration of the overlying skin may occur at an early stage. At first the tumor is more or less rounded and can be distinctly outlined. Later it becomes nodulated and diffuse. (d) Condition of the Nipple and Regional Lymph-nodes. — In the scirrhus more frequently than in the medullary form the nipple is both fixed and retracted. Ulceration may occur quite early at this point (Fig. 153). Pain is an early and marked symptom in carcinoma. There is early enlargement of the axillary and less often of the supraclavicular lymph-nodes (Figs. 148, 150, and 151). A systematic examination of these regions, as well as of the liver, if Fig. 155. — Edema of the Right Arm Due to Compression OF Axillary Veins, Two Years after Operation FOR Carcinoma of the Breast. Note the great difference in size between the right and left arms. 230 THORAX. palpable, should be made (Figs. 150 and 151) for evidence of lymph- node and visceral metastasis. The carcinomatous lymph-nodes are very hard and often adherent to each other. (e) Complications. — In addition to the early cachexia, cancer of the breast may produce metastases in the following places: 1. In the mediastinal lymph-nodes, causing cough and dyspnea (see Fig. 152). 2. In the lymphatics of the skin of the breast. The skin of the entire front of the chest has a board-like consistency and has been called "cancer encuirasse" (armor- like cancer). 3. Metastases in the lungs, liver, pleura, and brain. 4. Osseous metastases. If in the long bones, spontaneous fractures may occur after the most trivial injury. If the deposit occurs in the spine or skull, symptoms of pressure upon the spinal cord or brain occur when there has been no suspicion of a metastasis. A so-called paraplegia dolorosa is quite characteristic. 5. Edema of the hand (Fig. 155) from pressure of carcinomatous lymph-nodes on the axillary vessels. DIFFERENTIAL DIAGNOSIS OF TUMORS OF THE BREAST. Chronic Cystic Mastitis. Fibroadenoma. Carcixoma. Age Usually before forty, but In young women. Generally over forty, may occur before men- rarely before that age; opause, often more accompanied by painful and larger cachexia, during menses. Location and growth Multiple nodules in one Anywhere. Usually in inner quad- or both breasts. Very Grow very rants. Grow rapid- slow growth, except in slowly. ly. large cysts. Mobility Not movable in breast un- Freely movable. Movable in very earli- less one or more large est stage; later ad- cysts — then only mod- herent to skin or pec- erate mobility. toral muscle and fixed in breast. Consistency and form Large cysts either are Not as hard as Very hard, irregular, round and fluctuate or carcinoma; and not demarcated, are elastic. Smaller outline round- multiple nodules feel ed and sharp, like beans. Condition of nipple, and pain Very rarely refracted. No change. No Early retraction. Of- Tumors often painful, pain, as a rule. ten pain, quite severe especially at menses. and early. Condition of ax- illary lymph- nodes and me- tastases Earlier enlargement than Not enlarged, as Early enlargement. in cancer. Tender and a rule. Induration' very soft. Often more pain- marked. Evidence ful during menses. of metastases (see page 230). CHAPTER IV. THE ABDOMEN. Affections of the Abdominal Wall, inflammatory processes. Furuncles of the skin of the abdomen do not differ from those found elsewhere. It is interesting to note that they cause early enlarge- ment of the inguinal lymph-nodes which rapidly disappears as soon as the furuncle is incised and drained. Subcutaneous suppuration is usually secondary to an infected wound or to some more deeply seated infective process. There is more or less induration, so that it is difficult to detect fluctuation. There is also superficial pain, redness, fever, -and enlargement of the inguinal lymph-nodes. In the abdominal wall proper, suppuration may occur in a number of distinct spaces. 1. Within the sheath of the recti muscles following typhoid, or, rarely, an injury. The pus can only spread as far as the umbilicus, where it may perforate. The previous history, the location of the swelling, pain, and other inflammatory signs render a diagnosis easy. The swelling is more prominent when the patient lies down. 2. Retromuscular Suppuration. — The pus lies in the loose connective tissue between the individual muscle layers or between the transversalis fascia and peritoneum. All of these spaces communicate with each other freely and also with the connective tissue of the pelvis, iliac fossae, and retroperitoneal space. A special space, known as the prevesical or cavum retzii, is often spoken of as being separated from the retro- muscular space by a septum (see Fig. 156), but such a division is not found clinically, pus in one of these spaces spreading by direct contin- uity to any of the others. 'With the exception of the rare cases of idiopathic suppuration in the prevesical space, the majority of the cases of suppuration in the intermuscular and retromuscular spaces are secondary. They may be due to a number of different primary causes, which it is well to remember in making a diagnosis. (a) If prevesical, to cystitis or diseases of the prostate or seminal vesicles. 231 232 THE ABDOMEN. (b) If around the kidney, it is the result of an infection of the peri- nephritic tissue following some renal infection such as perinephritis. (c) If in the retroperitoneal connective tissue of the iliac fossa it may be due (a) to suppuration of the deep iliac lymph-nodes following phlegmon of the thigh or an inguinal adenitis; (/S) to tuberculosis or osteomyehtis of the pelvic bones. (d) It may be due to disease of the ribs or spine or to a spontane- ously perforated empyema (empyema necessitatis). (e) Secondary to perforations of the gall-bladder, intestine, appendix, stomach, and cecum. This group includes actinomycosis follow- ing primary intestinal disease. (/) Secondary to infections of the uter- us (especially puer- peral) and of the ad- nexa. Puerperal in- fection may cause a pelvic abscess which spreads to the connec- tive tissue of the iliac fossa and retroperi- toneal space (see Fig. 156). (g) The pus may collect in the extra- peritoneal subphrenic tissue secondary to ap- pendicitis or hepatic abscess. This is comparatively rare. The diagnosis in all of these is dependent upon the history and the presence of general and local symptoms of suppuration. Prevesical abscesses (see Fig. 156) give rise to an area of dullness of oval form like that of the distended bladder. There is local pain, ten- derness, and fever. When the bladder is emptied the tumor still re- mains. The pus may rupture into the bladder or into the intestine. The tumor can be felt through the rectum or vagina. Inquiry into thehistory will usually result in finding a primary focus in the bladder, the generative organs, the bones of the pelvis, or the intestine. In all of the other forms of suppuration within or behind the abdom- FiG. 156. — Location of Abscesses in Abdominal Wall, etc R, Rectum; U, uterus; B, bladder; 5, symphysis pubis; F, skin and subcutaneous tissues; W, muscles of abdominal wall; M, retro- muscular abscess; V, prevesical abscess; PP, preperitoneal abscess; P, peritoneum; RP, retroperitoneal suppuration extending upward from pelvis. TUMORS OF THE ABDOMINAL WALL, 233 inal muscles the diagnosis may be made from the appearance of a more or less circumscribed area of induration, accompanied by fever, pain, tenderness, and rigidity of the corresponding portion of the abdominal wall. Careful search will usually ehcit the primary source of infection. If there is pus, or even in the case of a tumor in the abdominal wall, both are more prominent when the patient lies down. In the major- ity of the forms of suppuration in or behind the abdominal wall the diagnosis can be made from the history of a primary infection, the pres- ence of a circumscribed or diffuse infiltration, pain, tenderness, and fever. TUMORS OF THE ABDOMINAL WALL. These may occur either in the skin itself or in the deeper layers. Those of the skin are usually soft pedunculated fihromata which vary greatly in size and number. Their soft consistency, slow growth, and pedunculation render their recognition easy (Fig. 375). Pigmented nevi also occur with considerable variation in size and number. They are of a brownish color, slightly raised above the surrounding skin, and often have long hairs growing from their surface. Both soft fibromata and pigmented nevi tend to become sarcomatous at times. Such a change can be recognized from the rapid growth of the tumor as well as the tendency to ulceration of the surface. The deeper forms of neoplasms are lipomata and desmoids. Lipomata occur as subcutaneous, intermuscular, and subserous growths. The two first named may be recognized by their soft, almost semifluctuating consistency, and especially by their lobulated surface, most marked, as in all Hpomata, when the overlying skin is sHghtly stretched. The subcutaneous lipomata occur most frequently in the median line. They are also lobulated, and cause pain, which is often referred to the stomach. They may be differentiated from hernias of the linea alba or umbil- ical hernia by palpation (Fig. 157). In the case of a hernia there is a distinct thrill on coughing and the contents can be reduced into the abdominal cavity unless they are adherent to the sac. In such cases, and when linea alba hemise become strangulated, a differential diagnosis from Hpomata is almost impossible before operation. The occurrence of subserous hpomata in inguinal and femoral hemise is frequently found at operations for the radical cure of these conditions, but they are seldom recognized before operation. ]^ Desmoids are peculiar forms of fibroid tumors, occurring chiefly in women between fifteen and fifty who have borne children. They rarely occur in men. The majority are in the front part of the abdomen 234 THE ABDOMEN. below the umbilicus. They are oval in form and vary in size from a hen's egg to that of an adult's head. As a rule, they are hard, but may soften so that cysts are formed which may be hemorrhagic. They may follow trauma, laparotomy or herniotomy operations, or the prolonged pressure of a belt. They may be painful, especially at the time of the menstrual period. The diagnosis depends on their firm character (the softer cystic degeneration being exceptional) upon the smooth surface, and the fact that they grow in the direction of the corresponding aponeurosis or scar. Fig. 157. — Method of Determining the Presence of an Umbilical Hernia. Two fingers, preferably the index and middle finger, of the examiner's hand are placed over the umbilical region, and the patient is asked to cough, when the impulse can be distinctly felt if the hernia is present. They may become less prominent when the patient sits up and can be less easily felt than when they lie down. They do not change their position when the patient is turned toward either side, as intraabdominal tumors do. Differential Diagnosis of Desmoids. — They must be differentiated from an abscess or hematoma of the abdominal wall and from intra- abdominal tumors. A hematoma is gradually absorbed, and an abscess is more sensitive and is accompanied by fever and leukocytosis. In addition, the edges of an abscess are less sharp and there is usually a primary cause (see page 231) to be found. CONGENITAL CONDITIONS. 235 From intraabdominal tumors and encapsulated exudates there is great difficulty at times in making a differential diagnosis, especially if they have become adherent to the anterior abdominal wall. If such an adherent intraabdominal tumor be due to carcinoma or sarcoma, there is accompanying cachexia and the history of a rapid growth as compared to the slow growth of desmoids. Other forms of intraabdominal tumors show the characteristics described on page 234. IT Fig. 158. — Most Frequent Conditions Occurring in Connection with Meckel's Diverticulum (Miles F. Porter). 5, Skin; M , abdominal wall. I. Posterior wall of Meckel's diverticulum prolapsed through umbilicus. II. Hernia of Meckel's diverticulum. A coil of intestine is seen pushing the posterior wall of the diverticulum outward. III. Intestinal obstruction due to Meckel's diverticulum. The latter is seen attached to some point in the abdominal cavity causing strangulation of a coil of intestine which had slipped beneath its point of origin and attachment. IV. Fistula at umbilicus due to patent Meckel's diverticulum. CONGENITAL CONDITIONS. These occur most often in connection with Meckel's diverticulum and the urachus. In the former, a number of conditions are found, as follows (Fig. 158): (a) The diverticulum may be patent at the umbilicus with pro- trusion of the posterior wall of the gut. This may be diagnosed from the presence of a soft reddish tumor covered externally with mucous membrane. ih) There may be simply a fistulous opening, with reddish edges, from which a few drops of mucus having a fecal odor are discharged and through which a fine probe can be passed into the intestine. 236 THE ABDOMEN, (c) A hernia of the gut may occur as a compHcation of the posterior wall protrusion. {d) The diverticulum may be large and patulous at the umbilicus. Such a form can be readily recognized. {e) The diverticulum may rarely be converted into a cyst. Malformations in connection with the urachus are much simpler. Here a fistula is most often present from which both pus and urine are discharged. Cysts of the urachus occur in the median line between the umbilicus and symphysis, and can be suspected to be of this origin chiefly from the characteristic median location. The connection of a fistula with the bladder may be demonstrated by injecting milk or methylene-blue into it and then catheterizing the patient. ABSCESSES DISCHARGING THROUGH THE UMBILICUS. Pus escaping from the navel may have its origin in a number of different sources. It may be the result of a prevesical or retromuscular suppuration dependent on the various primary sources of such infection (see page 231). In addition to the causes in the abdominal wall itself , one must think of intraabdominal causes. In children it is a frequent point of spontaneous discharge of a tubercular peritonitis. Suppurat- ing echinococcus cysts and abscesses resulting from perforations of the various hollow viscera, all are apt to discharge through the navel. TUMORS OF THE UMBILICUS. These may be primary and secondary. At times the discovery of the secondary growth at the navel may be the first sign of an intraab- dominal malignant disease. The primary tumors belong to both the benign and mahgnant forms. Of the former, the most frequent are dermoids and sebaceous cysts, which can be recognized by their soft doughy consistency and slow growth. The primary malignant tumors are almost always carcinomata and grow rapidly, appearing either in the form of a cauliflower-like growth with firm edges or as an ulcerating surface with typical indurated edges and base. There is also accompanying indurative enlargement of the inguinal lymph-nodes. The secondary tumors simply cause a hard tumor protruding at the umbihcus, and appear rather as the result of a direct continuation of a widespread peritoneal dissemination than as a metastasis. They are due in two-thirds of the cases to malignant disease of the alimentary INJURIES OF THE ABDOMINAL WALLS AND VISCERA. 237 tract or liver, in the remaining one-third to that of the ovaries and uterus. Injuries of the Abdominal Walls and Viscera. Our views in regard to the indications for operation have changed so rapidly during the past fifteen years that it has greatly influenced the question of diagnosis. Up to that time an exploratory laparotomy was only indicated in every suspected injury of the abdominal viscera if symptoms of peritonitis had appeared. At present more progressive surgeons believe that visceral in- juries resulting from stab or gunshot wounds, as well as severe crushing injuries, should be diagnosed early enough to be of aid in saving the patient's life, i. e., within the first six to twelve hours. When such a patient is examined for the purpose of making a diagnosis, a certain more or less fixed routine method should be followed in order to ascertain, as soon after the accident as possible, whether a viscus has been injured. Often such a decision can only be reached if the patient is examined a second or third time in a similar manner one to two hours later. The routine method is as follows: 1. Ascertain as accurately as possible the exact manner in which the accident occurred. 2. General condition of the patient. 3. Results of local examination. 4. Symptoms of injury of particular viscera. Before discussing these in detail, it may be stated that injuries in which there is no external wound are just as likely to produce serious visceral lesions, as those in which there is a cutaneous wound. In civil life the former class is far more frequent than the latter, and with the possible exception of those cases in which there is actual prolapse of viscera following the action of some penetrating force, the diagnostic points of both penetrating and non-penetrating wounds are the same, so that they will be discussed together. I. History and Mode of Accident. — In stab wounds it will be of confirmatory value to know the length of blade, the relative positions of victim and assailant, and the direction in which the instrument was thrust in if possible. In gunshot or shell wounds the size of the bullet or missile is of value. It has been found that small bullets travehng with great velocity do far less damage than larger and more explosive ones. Too much 238 THE ABDOMEN. weight should, however, not be placed upon this difference, since wounds of the hollow viscera may cause as serious results after small as after large perforations. In the case of subcutaneous injury we can divide them into those in which there is perhaps only slight abrasion or contusion externally, and the graver cases in which there is a hernial protrusion. The modes of injury are, as in the skull, chiefly of three varieties: (a) A circumscribed force or one which has come into contact with the abdomen over a limited area only. As examples of this class maybe mentioned kicks, or a fall upon some object, or a blow from a tool hke a hammer, etc., thrown at the lower portion of the patient's thorax or over the abdomen proper. (b) A diffuse force or one in which one segment or the entire abdomen has been compressed between two opposing forces. Such action fol- lows accidents like being caught between buffers or in the wreck of a building. (c) An indirect mode of injury such as follows a fall upon the feet or the falling of a weight upon the back. 2. General Condition of the Patient. — There are four classes of cases: {a) Those with marked primary shock symptoms from which the patient never recovers, death ensuing in a short time after the injury. (b) Those with marked primary shock symptoms passing imper- ceptibly into those of internal hemorrhage, either terminating fatally within a few minutes to hours, or the signs of internal hemorrhage continue so that a diagnosis of the injury of a viscus with escape of blood can be made. (c) Cases with practically no general symptoms and in which the suspicion of an abdominal injury only arises from the history of the mode of injury or the gradual appearance of local signs indicating hemorrhage or beginning peritonitis. There are also cases in which the symptoms appear on the second day, or even as late as the tenth day, from dislodgment of a clot. (d) Cases in which there is apparently considerable primary shock which clears up without any local injury being discovered. This last class is the most puzzling from a diagnostic point of view. Under shock symptoms may be included pallor of the skin and visible mucous membranes; rapid, weak pulse and respiration; cold, clammy sweat; stupor or unconsciousness; lowering of blood-pressure; dilated pupils; and vomiting immediately after the accident. In making an examination of the general condition of the patient INJURIES OF THE ABDOMINAL WALLS AND VISCERA. 23Q one should note whether the above symptoms of shock are present or absent. In case they are present and persist for more than a few hours, one must look for local signs of injury. If the patient does not react, one must look for some cause in the abdomen. Extreme pallor, a weak, rapid pulse with but little tension, thirst, restlessness, shallow respirations, and a decrease in blood-pressure, as determined by the Riva Rocci instrument, indicate internal hemor- rhage. If such is the case, it may be impossible to distinguish it from shock except by the absence of unconsciousness, of cold, clammy skin and dilated pupils in hemorrhage (see page 697). There are cases in which the symptoms of both shock and internal hemorrhage appear immediately after the accident, so that it is impossible to distinguish between them until some hours have passed and the hemorrhage symptoms predominate. If the condition is due to hemorrhage the patient becomes paler, more apathetic and somnolent, the pulse gets smaller and more rapid and the respiration shallower, even when there is no peritonitis present. The writer has, on the other hand, seen a number of cases of severe intraperitoneal hemorrhage in which the pallor was not a noticeable feature, the primary anemia having been partially recovered from. These exceptions are particularly mentioned to emphasize the fact, first, that in some cases it is almost impossible . to make a diagnosis before operation; and, secondarily, that too much reliance should not be placed on any one symptom. 3. Local Signs of Injury. — (a) Examination of the skin and abdominal wall. In the case of penetrating wounds the situation of the wound of entrance and of exit, if the latter exists, is of some value in determining which structure has been injured. In former times great stress was laid upon the fact that many gunshot or stab wounds did not penetrate into the abdominal cavity. At present the opinion of the majority of surgeons is that no time should be wasted in speculating whether or not a missile or knife has pene- trated, but exploratory laparotomy should be performed. Under no conditions should a wound be probed or enlarged, however, until the proper aseptic technic and surroundings have been secured in order to make a diagnosis by direct inspection. In injuries of the abdominal wall or viscera with but slight or no external signs one should note the presence of an accompanying frac- ture of the lower ribs or of cutaneous hematomata. In the same manner the presence of a palpable gap in the abdominal muscles, with or without the appearance of a swelling having all the character- istics of a hernia (see page 401), is of value. 240 THE ABDOMEN. The most important local signs, aside from those to be seen or felt externally in the early hours (six to twelve hours) after either a pene- trating or non-penetrating injury, are: (a) Muscular rigidity. (b) Localized or diffuse pain and tenderness on pressure. (c) Dullness in the flanks or above the pubes. The muscular rigidity is due to a reflex contraction of the abdominal muscles, called the "defence musculaire" by French surgeons. It is one of the most characteristic symptoms and is quite marked at an early stage over the injured viscus. The same is true for the pain and tenderness on Hght pressure which usually accompany the rigidity. These symptoms are indicative either (a) of peritoneal irritation due to the presence of blood, or (b) of peritonitis, due to the escape of bowel or bladder contents. This rigidity and tenderness extend over the entire abdomen. The steady increase in the pulse-rate and in the degree of tympanites, and the onset of vomiting, etc., soon show the presence of a complicating peritonitis. If pain is due to injury to the abdominal wall alone, muscular rigidity is never as marked. In the early hours after an injury, especially in those cases in which there are practically no signs of shock or internal hemorrhage, one can detect dulhiess in the flanks or above the pubes. Such dullness, if it changes to tympany when the patient is turned upon the opposite side, means free blood or urine in the peritoneal cavity. If the dullness is only above the pubes and does not vary with change of position it is due to an extraperitoneal rupture of the bladder (see page 243). Un- fortunately free fluid can seldom be demonstrated at an early stage owing to the muscular rigidity. At a later stage its presence is obscured by the tympanites. The author has found it most often above the pubes in intraperitoneal hemorrhage. 4. Symptoms of Injury of Particular Viscera. — A convenient division of the symptoms of injury of the individual viscera for the purpose of diagnosis is: (a) Those cases in which symptoms of injur}^ of the ahmentary canal predominate. (b) Those in which symptoms of injury^ of the urinary organs predominate. (c) Those in which signs of internal hemorrhage predominate. Symptoms of Injury of the Alimentary Canal. — Vomiting. — Nausea or vomiting continuing for some hours after the receipt of an injury are very characteristic signs of the presence of an injury to the stomach or small intestine. If the vomitus contains blood, it indicates an INJURIES OF THE ABDOMIXAL WALLS AXD VISCERA. 241 injury to the stomach. If the vomiting is bihous in character, a wound of the small intestine should be suspected. Obliteration of the Liver Dullness. — This sign, if present in the form of tympany replacing a normal hepatic dullness, is of great value. Unfortunately, however, it is rarely present, so that but little weight can be placed upon its absence. Presence of Evidence of Free Fluid in the Peritoneal Cavity. — As was stated above, the presence of free fluid in sufficient quantities to permit of its detection by percussion is so rare in the early hours of a stomach or intestinal injury as to be of little value. If, however, a changing line of dullness in the flanks and above the pubes can be found, it is indicative of such visceral perforation. One must, however, exclude the possibility of intestinal coils full of fluid feces or the possibility of free hemorrhage giving rise to the same signs. The most typical symptoms at an early stage of gastric or intestinal perforation are the gradual rise in the pulse-rate and the presence of an increasing leukocytosis. If an increase in the pulse-rate is not due to primary shock or hemorrhage, such an increase is strongly indicative of a beginning peritonitis. Tympanites. — If in a patient who has sustained an injury of the abdomen in any of the modes above described there is a gradual in- crease in the distention of the abdomen and other symptoms, such as inability to pass flatus, there can no longer be any question as to the existence of a perforation. As was stated above, in the majority of cases a diagnosis made when tympanites is marked is of comparatively little value from an operative standpoint, since septic paresis of the intestines is already well advanced. The passage of blood in larger or smaller quantities with the bowel movement is also a positive sign of intestinal injury. If black and tarr\" in character, it indicates hemorrhage high up toward the stomach or the duodenum. If fresher in color it indicates hemorrhage lower down. The pain, tenderness, and rigidity of the abdominal wall are often quite localized in gastric or intestinal injur}-. This is especially true of those cases of appendicitis which apparently seem to follow directly upon the reception of an injury. Symptoms of Injury of the Urinary Organs. — This includes injuries of the kidneys and ureter. Injury of the Kidney. — If the wound in the kidney communicates freely with the general peritoneal cavity, it produces the same symptoms of internal hemorrhage as those in which there is perforation of solid 16 242 THE ABDOMEN. viscera like the liver and spleen, and will be referred to below. Injury of the kidney in which there is no such communication causes pain, and not infrequently, swelling over the lumbar region. The pain is apt to radiate along the ureter into the testis or thigh upon the side of the injury. There is also tenderness over the kidney and considerable rigidity of the lumbar muscles. The most characteristic symptom, however, of injury to the kidney is the presence of hematuria. In bleeding from the kidney the blood is intimately mixed with the urine and accompanied by worm-like clots which are casts of the ureter, whose passage down along the ureter cause the colicky pains just spoken of. The hematuria is, as a rule, most marked just after the reception of an injury, gradually diminishing in quantity. Even the Fig. 159. — Extensive Destruction of Kidney. The organ is completely lacerated. It occurred in a case of subcutaneous injury of the abdominal wall with- out external sign. (See text.) symptom of hematuria may at times be absent, and yet extensive lacerations of the kidney have occurred, as in the case recently observed by the author in which there was pulpification of the kidney without any blood in the urine, as a result of a crushing injury. The ureter was blocked by a large clot so that no hematuria occurred. Fortunately such cases are very rare. In order to state positively that hematuria is from the kidney the bladder should be washed out and some of the irrigating solution left in the bladder. This rapidly becomes tinged with blood as the latter escapes from the ureter and passes through the catheter which has been left in place. In some cases the above symptoms of injury to the kidney may be accompanied by evidences of displacement of the kidney, as determined by palpation of the abdomen (see Fig. 160). INJURIES OF THE ABDOMINAL WALLS AND VISCERA. 243 It is impossible to diagnose an injury of the ureter until a tumor forms along the course of the ureter and is accompanied by diminished secretion of urine and hematuria. Injuries 0} the bladder may be intraperitoneal or extraperitoneal. In extraperitoneal tears there are evidences of dullness above the pubis, the area of dullness not changing with change of the position of the patient; or there is bulging toward the rectum at the base of the bladder, to be felt per rectum. Intraperitoneal ruptures of the bladder cannot be differentiated Fig . 160. — Method of Examination to Determine Abnormal Mobu.ity or Enlargements of the Kidney. This method is also used in the determination of the presence or absence of an enlargement of the kidney. The right hand of the examiner, when examining the right kidney, is placed behind the patient in a space be- tween the last-rib and the crest of the ilium, so that the parts lying behind the kidney can be raised up to meet the opposite hand, which is pressed down upon it. When examining for a floating kidney the lower pole of the kidney can be felt to slip across the hand lying on the anterior surface of the abdomen. as such except when symptoms of peritonitis appear. A diagnosis at this time, as was stated before, is of comparatively little value from an operative standpoint. In both extraperitoneal and intraperitoneal ruptures of the bladder the catheter can be easily passed into the bladder. The urine is slightly blood-tinged, much less than in injuries of the kid- ney, and the quantity of urine obtained is very small or there may be none at all. The injection test for perforation or rupture of the bladder is but Httle to be relied upon. This test consists in inserting into the bladder 244 THE ABDOMEN. a definite quantity, usually from four to six ounces, of sterile water. If the bladder is perforated, the greater portion or all of this leaks out into the peritoneal cavity or into the extraperitoneal tissue, and a smaller quantity than was put in returns through the catheter. This test is unreliable because the tear or perforation may be valve-like in character, allowing but a small quantity to escape, or the urethra may be torn at the neck of the bladder. The most reliable signs of injury of the bladder at an early stage are (a) the history of and the location of the injury; (&) the presence of practically no urine in the bladder when catheterized, and this bloody and in small quantity; (c) the pain over the bladder; (d) the con- stant desire but inability to urinate. When peritonitis has set in, it is impossible to state in any case whether this has been due to perforation of the bladder or of some portion of the alimentary canal. Fractures of the pelvis are often accompanied by injuries of the bladder and urethra (see page 490). Cases in which Symptoms of Internal Hemorrhage Predominate.- — These will be found more or less characteristic of ruptures of the liver or spleen or of the intraperitoneal ruptures of the kidney. Pain, localized tenderness, and rigidity situated over the splenic region, accompanied by evidences of hemorrhage into the peritoneal cavity, are indicative of injury of the spleen. The same symptoms located over the region of the liver, especially if the pains radiate to the shoulders, are typical of injuries of the liver. In injuries of the liver and spleen, and in those of the kidney in which the blood escapes into the general peritoneal cavity, the diagnosis may be made from these local signs, such as tenderness, rigidity, etc., added to the presence of evidences of a shifting line of dullness in the flanks, i. e., of free fluid in the peritoneal cavity. Icterus, when present, is of great value as indicating an injury of the liver. The presence of free blood in the peritoneal cavity, whether due to an injury of the omentum or of the mesentery, of the deep epigastric artery, or of the liver, spleen, or kidney, causes early symptoms of so-called peritonism or peritoneal irritation. These are similar to those of a beginning peri- tonitis, but are less rapid in their onset. They consist of gradually increasing pulse-rate, tympanites, and leukocytosis. These, however, gradually subside if the blood remains aseptic and is absorbed. Injuries of the pancreas cause shock, vomiting, and localized pain over the epigastrium, and often distention of the upper abdomen. Fractures of the ribs accompany the subcutaneous injuries of the liver and spleen in many cases. ACUTE ABDOMINAL AFFECTIONS. 245 Acute Abdominal Affections. When called to the bedside of a patient suffering from an acute abdominal condition, every effort should be made to make a diagnosis at as early a period as possible. This diagnosis should not only include the viscus involved, but the character of the pathologic process. In the examination of such a case it is well to have a more or less routine method of examination, in order that no organ may be over- looked. There is no one group of symptoms common to all acute abdominal Fig. 161. — Locations of Various Foci of Suppuration in Abdominal Cavity. SPA, Subphrenic abscess pushing hver away from abdominal wall; RLA, abscess of right lobe of liver LLA, abscess of left lobe of liver; PS, peri-pancreatic suppuration; A'', location of abscesses within kidney (pyelonephritis); PN, location of perinephritic suppuration; P, peritoneal cavity; Si, lumen of stomach; 5, abscess of spleen; R, retroperitoneal tissue. conditions. On the other hand, symptoms so group themselves that it will be found of aid to divide the cases into four classes. The lines between these are not sharply drawn because occasionally cases appar- ently belonging to one group will be found to belong more properly to one of the others. For practical purposes, however, such a class- ification will be found useful clinically, and is as follows : 1. Those in which inflammatory symptoms appear early and predominate. 2. Those in which pain of varying intensity is the prominent s}Tnp- tom. It may be followed by signs of localized or diffuse peritonitis or by the symptoms of intestinal obstruction. 246 THE ABDOMEN. 3. Those cases in which the symptoms of intestinal obstruction are the most prominent from the onset. 4. Those in which either shock or hemorrhage or both are marked, and are followed by signs of peritonism (signs of bowel paralysis of milder degree than in obstruction). The various acute conditions which can thus be classified are: GROUP I. GROUP II. GROUP III. GROUP IV. Pain a Prominent Early Symp- Early Signs of Early Signs of Early Symptoms of Suppura- tion. tom FOLLOWED OR NOT BY Signs of Peritonitis or In- testinal Obstruction. Intestinal Obstruction. Internal Hemorrhage. I. Acute cholecystitis. I. Appendicitis. All forms of in- I. Extrauter- testinal ob- ine hem- 2. Hepatic infections. 2. Gallstones or biliary struction. orrhage. (a) Single or tropical ab- colic. (a) Strangula- scess. tion by bands, 2. Rupture (b) Suppurative pyle- 3. Perforation of hollow by adhesions of aneur- phlebitis. viscera. through aper- ysms. (c) Catarrhal and sup- (a) Gastric ulcer. tures, or by purative cholangitis. (b) Duodenal ulcer. Meckel's di- (c) Typhoid ulcer. verticulum. 3. Primary forms of peri- (b) Volvulus. tonitis. 4. Acute pancreatitis. (c) Intussus- (a) Acute tubercular. ception. (b) Pneumococcus. 5. Renal colic. ■ (d) By tumors (c) Gonorrheal. or foreign 6. Kinking of ureter in bodies. 4. Renal infections. floating kidney (Dietl's (e) Adynamic (a) Pyonephrosis. crises). ileus. (6) Pyelonephritis. (c) Perinephritis. 7. Embolism or thrombo- (d) Metastatic abscess. sis of the mesenteric vessels. 5. Subphrenic abscess. 8. Torsion of pedicles of 6. Suppurating echinococ- ovarian or uterine tu- cus cysts of the liver. mors. 7. Pericolitis sinistra. 8. Multinle abscesses of 9. Torsion of spermatic cord. omentum. ID. Visceral crises in tabes or in erythema group. 11. Angina sclerotica abdominis. 12. Referred pain from thoracic or spinal affections. 13. Inflammation of intraabdominal portion of vas deferens. Group I. — Early Symptoms of Suppuration. I. ACUTE CHOLECYSTITIS. In acute cholecystitis, occurring without gallstones, there is pain referred to the gallbladder region, tenderness and muscular rigidity over the same area, fever, leukocytosis, and an increased pulse-rate. In ACUTE CHOLECYSTITIS. 247 addition, an area of dullness can be outlined by percussion and a tumor felt at times by palpation just below the right costal arch. If the liver is located at a lower level in the abdominal cavity, as the result of a hepatoptosis, or if there is a long Riedel's lobe which has carried the gallbladder with it (Fig. 162), all of the above signs are found at the level of the umbiHcus or even below it. If pus has formed in the gallbladder (empyema) the fever is higher and continuous in type, and the leukocytosis quite marked. In cholecystitis complicating typhoid the symptoms are often overshad- owed by those of the typhoid itself. Such cases show a distinct Widal reaction. Differential Diagnosis. — i. Ap- pendicitis . — In ap- pendicitis the tender- ness and rigidity are lower down, fever and leukocytosis are not so marked at an early stage, and there is more apt to be severe colicky pain. If, however, the gallbladder is located lower than normal the differentiation be- tween a cholecystitis and an appendicitis may be very difficult. 2. Biliary Colic. — ^In gallstone colic the same local signs appear as in cholecystitis, but there is less fever, less leukocytosis, and less constitutional disturbance, and the pains are far more severe and radiate to the right shoulder, less often than to the left. Phlegmonous Cholecystitis. — This grave form of cholecystitis can be recognized by the greater severity of the initial symptoms. The pain in the right hypochondrium is more severe and sudden in its onset than in gallstone colic, and there is far more general disturbance. These latter septic symptoms are rapid, feeble pulse, cold sweats, sub- FiG. 162. — Riedel's Lobe of Liver and Area of Dullness or Tumor Due to Cystic Enlargement of the Gallbladder. RL, Right lobe of liver ; LL, left lobe of liver ; R, Riedel's lobe ; CG, cysticaUy dilated gallbladder. THE ABDOMEX, normal temperature, collapse, faintness, great prostration, and the early appearance of the signs of a general peritonitis. 2. HEPATIC INFECTIONS. SINGLE OR TROPICAL ABSCESS. The occurrence of irregular fever accompanied by chills, sweats, and pain over the Hver and enlargement of that organ, in a patient who has previously suffered from dysen- tery, should lead one to suspect an abscess of the hver. A bulg- ing below the right costal arch will con- firm such a diagnosis. The pain in ab- scesses of the right lobe is referred to the right shoulder, and in those of the left side, to the corresponding scapular region. The fever may be quite regularly inter- mittent, like a malar- ial, but is usually quite irregular. The liver is en- larged in all directions and is tender to the touch. The tender- ness may at times be quite localized over the abscess. Exploratory puncture is of great value in confirming the presence of pus. A negative result does not exclude an abscess, as the needle may become occluded or pass through the abscess. Differential Diagnosis.— i. Empyema. — The Hver is not enlarged in a do^^Tlward direction. There are marked signs of compression of the lung if the empyema is a diffuse one and the upper border of dull- ness is either concave upward or horizontal, while in hepatic abscess it is convex (Fig. 163) and the septic symptoms are more marked. If Fig. 163. — Areas of Dullness Frequently Observed m Right- sided Subphrenic Abscesses, and in Abscesses of the Right Lobe of the Li\'er. RL, Right lobe of liver; LL, left lobe of liver; LA , abscess of lateral subphrenic space; DA, abscess of dome of diaphragm. HEPATIC INFECTIONS. 249 an empyema and hepatic abscess coexist a differentiation is impossible. The same is true for an encapsulated diaphragmatic empyema. 2. Malaria. — The absence of leukocytosis and the finding of Plas- modia serve to distinguish this disease. It must not be forgotten that in some cases of malaria the organisms are not found until after quinin has been administered. 3. Suppurative Pylephlebitis or Cholangitis. 4. Subphrenic Abscess. — (See page 253.) SUPPURATIVE PYLEPHLEBITIS. This most frequently follows appendicitis, toward the end of the attack. It results in the formation of multiple abscesses in both lobes of the liver (Fig. 164). It may often follow what were interpreted clinically to have been mild cases of appendicitis. Fig. 164. — Multiple Abscesses OF Liver. Due to a septic pylephlebitis secondary to appendicitis. If a septic or pyemic condition follows appendicitis either a pyle- phlebitis or a subphrenic abscess must be thought of. In pylephlebitis there are chills, irregular fever, sweats, jaundice, and a uniformly enlarged and very tender liver. The patients appear to be very septic and soon succumb to the pyemia. Differential Diagnosis. — i. From Tropical Abscess. — The clinical picture is not that of such a severe sepsis as in pylephlebitis, the liver is not so uniformly tender, and there may be bulging at the costal arch. 2. Suppurative or Catarrhal Cholangitis Complicating Gallstones in the Common Duct. — There is continuous or intermittent jaundice, a'history of colics, and the septic intoxication is never as marked as 250 THE ABDOMEN, in pylephlebitis. If multiple foci of suppuration occur in a cholangitis, it can only be differentiated from a pylephlebitis by the history of an appendicitis in the latter. 3. Typhoid Fever. — The fever is almost always continuous, the pulse is slower, chills and sweats are rare, and there is leukopenia. A positive Widal reaction and the typhoid bacilli obtained from a blood culture are characteristic of typhoid. 4. Malaria. — The finding of plasmodia, the presence of leukopenia, and the more regular type of intermittent temperature, as well as the lack of local hepatic symptoms, speak for malaria. 3. PRIMARY FORMS OF PERITONITIS. Acute Tubercular Peritonitis. — This may begin in an acute manner with fever to 103° to 104°, abdominal tenderness, and the symptoms of ordinary acute peritonitis, such as tympanites, etc. In these cases the absence of a cause for the peritonitis and the examina- tion of the lungs and other parts of the body for evidence of tubercu- losis will be of aid in making a diagnosis. Acute Gonorrheal Peritonitis. — This is usually well localized in the pelvis, but may become general. In the former case the inflam- matory signs, such as severe pain, tenderness, muscular rigidity, and tympanites, are local. In the general form there is a very acute onset, in which abdominal distention, tenderness, and rigidity are quite diffuse and are accompanied by elevation of temperature and a rapid pulse. The diagnosis may be made from the previous history of leukorrhea or of post-marital infection, or of a preceding py ©salpinx followed by the acute local or general peritonitic symptoms. The fact that the condition spontaneously improves in a few days, instead of being progressive as in ordinary diffuse forms of peritonitis, is also very important. Pneumococcus Peritonitis. — This occurs almost exclusively in young children of both sexes. It may accompany or follow thoracic conditions, such as pericarditis or empyema, or occur independently. The diagnosis may be made from the age and the sudden onset of peritonitic symptoms, such as fever, abdominal distention, vomiting, and tenderness, followed in a few days by diarrhea and later by the for- mation of a tense cystic mass in the hypogastrium accompanied by fever and signs of exhaustion. RENAL INFECTION. 25 1 4. RENAL INFECTION. Renal suppuration is usually chronic in its course, but it may appear in such an acute form as to necessitate its consideration here. The principal varieties of acute renal disease of the suppurative type are: 1. Pyelonephritis. 2. Perinephritis. 3. Metastatic abscesses. 4. Pyonephrosis. PYELONEPHRITIS. This may follow suppuration in the lower urinary tract, such as the bladder or urethra, or it may be hematogenous in origin, i. e., conveyed through the blood from distant foci of suppuration. In some cases it manifests itself by a rigor or succession of chills, followed by fever and sweats. There is scarcely any tenderness or pain over the kidney in some cases; in others there are typical colicky pains following along the ureter to the bladder and radiating to the testis and thighs. The diagnosis in the first class of cases, where there are no local renal signs and the urine is negative, is very difficult and can only be made from the existence of a cystitis or other cause of infection, and the absence of signs of a pyemia or of a mahgnant endocarditis. In the more locahzed form the enlarged tender kidney and the ureteral pains, associated with purulent acid urine, are characteristic. In some of these cases the chills and irregular fever are followed by a more coQtinuous type of fever, resembling typhoid, with stupor and delirium, a condition known as urosepsis. Differential Diagnosis.— P)'^;?^/^. — In this septic condition there are signs of secondary foci in the lungs, spleen, and joints, which are absent in suppurative pyelonephritis, and in pyemia a primary focus is usually to be found. Septicemia. — In the acute forms septicemia runs a more rapid course, the pulse and respirations are higher, and there is greater prostration. PERINEPHRITIS. In this affection there is pain in the lumbar region, at times radiat- ing into the thigh or testes. The pain is usually quite severe, and the corresponding renal region is very tender, rigid, and often edema- tous. These local signs are accompanied by evidences of deep-seated suppuration, such as chills, fever, furred tongue, vomiting, stupor. 252 THE ABDOMEN. and even delirium. There is often a peculiar lameness; the patient walks with the body bent forward and inclined to the affected side, the thigh being held flexed. The urine may be normal if the disease be of extraneous origin, or it may contain blood if it follow an injury, or, finally, in a few cases there is pus in the acid urine. Differential Diagnosis. — i. Lumbago is but rarely accompanied by fever or leukocytosis. The pain is most often bilateral and does not radiate to the testis or thigh, 2. Spondylitis. — The pain extends around the body; it is relieved by suspending the patient. The tenderness is over the spine itself, which is held in a rigid manner, best seen when the patient is asked to bend forward. There is also but little fever or leukocytosis and the symptoms are more gradual in their onset. 3. Hip-joint Disease. — The pain and tenderness are lower down, often referred to the knee. There is limitation of motion at the hip, and when the limb is straightened there is marked lordosis of the lum- bar spine. The x-xdij often shows a pathologic head of the femur. 4. Appendicitis. — In those cases in which the appendix is directed down or inward (Fig. 168) the pain is in the right iHac fossa and followed by nausea and vomiting. In perinephritis the pain and swelling are higher up in the iliocostal space. In inflammation in an appendix which lies behind the cecum and ascending colon with its tip directed upward, the rigidity of the abdominal wall, tenderness, and pain may greatly resemble those of a right-sided perinephritis. In appendi- citis, however, the pain is usually followed by nausea and vomiting. The rigidity and swelling, etc., of a perinephritis usually extend fur- ther back in the iliocostal space. METASTATIC SUPPURATION OF THE KIDNEY. If this occurs as a manifestation of pyemia it cannot be recognized except from the locahzed pain and the sudden pyuria. If, however, as not rarely occurs, abscesses form in one or both kidneys, as the result of a purulent focus elsewhere which has not caused pyemia, the severe pain over the affected kidney, the occurrence of repeated chills and fever, and the tenderness and enlargement of the affected kidney will permit a diagnosis to be made. PYONEPHROSIS. This affection is not apt to run an acute course. The enlarged kidney can usually be distinctly felt as greatly enlarged, there is no rigidity of the abdominal muscles, no edema of the skin, and there is i3 tit S t= P D. 5 ^tJ '^ B o. H ^ a g^ "^ 55 3 £2- -^ 5' ■ P 'T3 _ cr 5" 5" n> '<; n oj rt (i 5. n £^ "> 2 2 P ^ ^ ,— rD «■ 2 o w re SUBPHRENIC ABSCESS. 253 a history of long duration of the symptoms. In some cases there is a previous history of an obstinate lumbago which was never properly diagnosed as of renal origin. In other cases there is a history of attacks of renal colic. 5. SUBPHRENIC ABSCESS. (See Figs. 163 and 165.) This condition most frequently follows appendicitis if situated in the right subphrenic space, and perforations of the stomach or duo- denum if located in the left subphrenic space. It may, however, occasionally occur in the latter locality after an acute appendicitis or a diffuse septic peri- tonitis. The attack of appendicitis need not have been complicated by pus formation and the subphrenic abscess may follow days to months after the at- tack. The history of a sudden recurrence of fever and of other signs of suppuration, such as leukocytosis, etc., toward the end of or shortly after an at- tack of appendicitis associated with pain in the right or left hepatic region, should lead to a search for a sub- phrenic abscess. In the case of the left- sided abscesses following gastric or duodenal ulcer there is a previous history of pain in the epigastrium and of vomiting of blood, or of copious tarry stools followed by the symptoms of infection. The diagnosis must be based on the physical signs and the general evidence of deep-seated infection, such as fever, rapid pulse, leukocy- tosis, etc. Fig. 166. — Area OF Dullness in I.eft-sided Subphrenic Abscess. The dark area shows absolute dullness, the area indicated by vertical lines corresponds to the zone of tympany (A. Martin). 254 THE ABDOMEN. In right-sided subphrenic abscesses the liver is usually pushed down- ward. Over the abscess there is a continuation upward of liver dullness for a variable distance with a corresponding suppression of pulmonary- sounds. A subphrenic abscess may cause a horizontal line of dullness or one that is convex upward. The area of dullness may be more marked at some one point, thus resembling an encapsulated empyema. If gas is present in the abscess, dullness is replaced by tympany and there are succussion sounds, as in pyopneumothorax. The pain may be strictly localized over the right or left hypochon- driac regions or may be diffuse, and not infrequently there is tenderness and rigidity, rarely edema of the overlying tissues. Differential Diagnosis. — Empyema.- — This is at times very diffi- cult. Rapid respiration, cough, expectoration, and the history of a preceding pneumonia speak for empyema. The line of dullness in the diffuse form is said to be concave upward, but this may occur in subphrenic abscess as well. Between an encapsulated empyema close to the diaphragm and a subphrenic abscess, differentiation is impossible. The physical signs for both empyema and subphrenic abscess are so nearly alike that greater reliance should be placed on the etiology and character of the pus obtained by exploratory aspiration. The latter is apt to have the peculiar acid fetor of colon bacillus pus, while in empyema there is seldom any odor. Again, in subphrenic abscess the explorator}^ puncture reveals the presence of pus at a lower level than in empyema. Abscess of the Liver. — Here the history of a preceding attack of dysentery and the less marked extension of the liver dullness upward are of value. In multiple abscesses of the liver following appendicitis there is greater evidence of sepsis and more general enlargement and tenderness of the liver. 6. SUPPURATING ECHINOCOCCUS CYSTS OF THE LIVER. These may present the same symptoms and local findings as single or tropical abscesses. There is, however, no history of dysentery, and the occupation of the patient frequently is suggestive in that the disease is much more common in those- brought in close contact with sheep and sheep-dogs. In the absence of a distinct tumor and the history or evidence of the presence of similar cysts elsewhere, a recognition of this condition is impossible. When the tumor is distinct, as is often the case, aspiration will frequently show booklets. MULTIPLE ABSCESSES OF THE OMENTUM. 255 7. PERICOLITIS SINISTRA. This is a condition of acute infection due either to perforation of the appendices epiploicae or of the haustra or saccuH of the descending colon and sigmoid flexure. There is sharp pain in the left iliac region, with rise of temper- ature and vomiting, the same sequence of symptoms so frequent- ly seen in appendicitis. On palpation there is deep tenderness, rigid- ity of the abdominal wall, and the forma- tion gradually of a tumor in the left iliac fossa accompanied by fever and leukocytosis. If no localized in- traperitoneal abscess forms, the pus, as in one case observed by the author, can escape into the general peri- toneal cavity and cause a diffuse peritonitis. ^'''- ^^V.-Most frequent D^ec.ion oe radiation oe Pain in '^ Various Acute Abdominal Afeections. L and G, Gallbladder and hepatic affections; GU, and DU, and F, location of pain in gastric and duodenal ulcers and pancreatic affections; D, occasional radiation of pain in duodenal ulcers to right iliac region; C, location of pain in ordinary intestinal colics, and in early stages of acute appendicitis; App, various radiations of pain in appendiceal inflammation; R, radiation of pain in ureteral and renal conditions, along the line of the ureter toward the bladder, testes, and thighs; S, location of pain in sigmoiditis, and affections of the descending colon. The arrow pointing downward and in- ward from the left nipple is to indicate the frequent reference of pain in thoracic affections, to the abdomen. MULTIPLE AB- SCESSES OF THE OMENTUM. Tliis condition may follow abdominal op- erations, especially those for radical cure of hernia. The clinical histor\^, as observed in one such case by the author, was the following : Severe pain in that side of the abdomen upon w^hich the wound was situated, with rigidity and tenderness. The temperature varied between 101° and 104° F., there was considerable abdominal distention, some vomiting, and constipation. A distinct tumor could be felt extending from Poupart's ligament 256 THE ABDOMEN. toward the umbilicus. The greatly thickened omentum in these cases contains a number of small abscesses. The diagnosis depends upon the signs of localized peritonitis with formation of tumor, following an operation. Group II. — Pain a Prominent Early Symptom, In this group all of those acute conditions are included in which the chief symptom is pain. This is accompanied by other signs of involve- ment of the abdominal viscera. In many of the conditions the pain can be localized fairly well from the onset ; in others, such as appen- dicitis, it is often dif- fuse at first, becoming more definite in the course of a few hours. I. APPENDICITIS. Diagnosis. — In every case of appendi- citis the diagnosis may be made from an al- most constant triad of symptoms : 1. Pain of a sud- den, severe, often col- icky nature. 2. Nausea and vomiting. 3. Localized ten- derness and muscular rigidity. I. Pain. — This is often general at first, but soon becomes locaHzed, in the majority of cases, in the right ihac region. The only exceptions to this rule are: {a) When the appendix is directed upward toward the hver, and especially when it Hes behind the ascending colon (Fig. 168), the pain may be referred to the lumbar or right hypochondriac regions. Fig. 168. — XoRiiAL Positions of Vermiform Appendix. I, Pointing downward and inward toward the pelvis; 2, point- ing inward and to the left; 3, pointing upward toward the liver, and lying either in front or behind the cecum. G, Normal location ot gallbladder; Sp, spleen; L, Uver; the letter itself is placed on the left lobe. APPENDICITIS. 257 (b) When the appendix points inward or toward the pelvis, the pain is referred either to the umbiHcus or to the left iliac region (Fig. 168), and is often accompanied by vesical and rectal symptoms. 2. Vomiting. — This accompanies the pain as a primary symptom or follows it after three or four hours. If the nausea and vomiting persist or reappear at a later period, they are danger-signals of a beginning peritonitis. 3. Tenderness and Muscular Rigidity. — As a rule, these are most Fig. 169. — Method of Examination of the Appendix Region, with the Limbs Flexed upon the Abdomen. The limbs should be raised to such a height that the soles of the feet can rest easily on the bed or table. The patient's back should be somewhat elevated, and he or she should be instructed to relax the abdomi- nal muscles by diverting his attention or asking them to open the mouth. Pressure is then made along the right border of the right rectus, with the entire palmar surface of all of the fingers of the right hand, and not with the tips of these fingers. marked over the right iliac region and are best elicited when the shoulders are raised and the thighs flexed (Fig. i6g). The tenderness is quite superficial and manifests itself when the shghtest pressure is made. Deep tenderness can be found only with difficulty during the acute stage, owing to the muscular rigidity. The examination should never be forcible. A good plan is to have the patient palpate the abdomen gently with the index-finger and ask him to locate the most tender point. Often the most marked tenderness can be obtained by rectal or vaginal 17 258 THE ABDOMEN. examination. The rectal method is especially of value in children, where the appendix so often points toward the pelvis. The muscular rigidity, being due to a reflex contraction, is a very valuable sign when it accompanies pain, vomiting, and tenderness. This symptom is best obtained by gradually and lightly sliding the hand over the suspected region. If the appendix lies in either of the unusual positions referred to above, the tenderness and rigidity are correspondingly altered in loca- tion (Fig. 167). Fig. 170. — Method of Palpating the Appendix with the Limbs Outstretched. The fingers are laid flat upon the abdominal wall, the examiner standing to the right of the patient. Either the right or left hand may be used. The appendix may usually be felt on the outer edge of the right rectus muscle, if enlarged, and if the abdominal walls are relaxed. Palpation should be carried out with as large a surface of the fingers as possible, and not by prodding the patient's abdomen with the finger-tips. This method is inferior to that shown in Fig. 169. Pulse. — In the majority of cases there will be an increase in the pulse-rate with the onset of pain. The rate may be from 80 to 100 for a number of hours. // it shows a gradual increase in frequency after the first twelve hours it is, as a rule, an ominous sign. The steady rise of the pulse- rate to no, later to 120 or higher, especially if it is jerky in character, is of great value in the diagnosis of a beginning peritonitis, especially if nausea continues, or vomiting is repeated and the area of rigidity and tenderness increase and are combined with abdominal distention. In children the pulse-rate is much higher than in adults and a rapid pulse is not always to be relied upon. APPENDICITIS. 259 Fortunately for the purpose of diagnosis a slow pulse is but rarely met with. The author recalls a pulse of 66 and a temperature of 99.6° in a case of extensive spreading peritonitis following appendicitis. The muscular rigidity, tenderness, and tympanites were so characteristic that a diagnosis could be made from these symptoms alone. Temperature. — A rise in temperature usually occurs within two to three hours after the beginning of an attack. In the milder catarrhal cases it is not higher than 100° or 101° F., but even this is inconstant. If fever persists and increases gradually during the first forty-eight to seventy-two hours, it generally means an encapsulated abscess. If the temperature drops suddenly, es- pecially if accom- panied by a rise of pulse-rate and in- crease of rigidity, it is significant of gangrene or a beginning peri- tonitis. Persistent temperature or fever occurring after ap- parent recovery, signi- iies some complication like pylephlebitis or subphrenic abscess. The most accurate temper- atures are those taken per rect-um. Leukocytosis. — Catarrhal appendicitis is accompanied by a mild degree of leukocytosis, rarely above 12,000. An increasing leukocy- tosis, from 15,000 upward, generally indicates a severe infection. If the count remains stationary, it is indicative of a walhng off. If the leukocyte count decreases gradually in a mild attack, it signifies improvement. If it decreases suddenly after a severe attack, it signifies gangrene, perforation with beginning peritonitis, or the Fig. 171. — Most Frequent Locations of Intraabdominal Ab- scesses Following Appendicitis. For subphrenic abscesses, see Figs. 163 and 166. i, Around cecum and appendix, close to brim of pelvis; 2, pelvic form; 3, around ascending colon and hepatic flexure; 4, retrocecal and colic forms; 5, left-sided forms. 5, Anterior superior spine of ilium. 26o THE ABDOMEN. bursting of an abscess into the general peritoneal cavity. The majority of cases in which perforation or gangrene occurs early, and causes peritonitis, have a low leukocyte count, owing to the lack of resistance on the part of the organism and the overwhelming of the system by the toxins. Tumor. — As an early sign this is of little value, owing to the fact that the muscular rigidity is so marked in many cases that deep pal- pation is both difficult and dangerous. In other cases the contracted edge of the rectus is apt to feel like an inflammatory mass. Again there are cases where the omentum wraps itself around the appendix and forms a palpable tumor. When the acute symptoms have sub- sided, a tumor can often be felt through the less rigid muscles. Rectal examination should never be omitted, especially in children, where the pelvis is shallow and the appendix is more apt to be located in it. Differential Diagnosis. — Acute Gastro-intestinal Disturbances. — In these, as in appendicitis, there is often a history of indiscretion in diet, followed by abdominal pain and vomiting. In acute gastroduo- denal catarrh the pain is felt over the epigastrium and is never as severe or colicky as in appendicitis. The nausea and vomiting are far more marked early symptoms, and may be almost constant. There is no true muscular rigidity and but shght, if any, tenderness. In intestinal colic the pain may be as severe as in appendicitis, but is usually referred to the umbilicus and does not become more intense, as it does in appendicitis. There is also no locaHzed rigidity or tenderness and the attack often subsides as soon as an enema is given, while in appen- dicitis the symptoms become more marked from hour to hour. In some cases of intestinal colic there is accompanying vomiting, diarrhea, and flatulency. There is an absence of any local rigidity and tenderness and the pains, if present, are more diffuse. Intestinal Obstruction. — In the first twenty-four to forty-eight hours there is no difficulty in distinguishing this condition from appendicitis. When, however, peritonitis has begun and caused a septic paralysis of the intestines, it is impossible to distinguish them, except from the history. In intestinal obstruction, if there is any localized pain, it is referred to the umbilicus. A systematic examination of the hernial openings often reveals the cause of the obstruction. Volvulus pains are referred to the left side of the abdomen and early distention of this half of the abdomen is most marked. Obstruction from volvulus, tumors, and bands is more common in adults. In children intussusception is more frequent, and a tumor can often be felt per rectum or in the c 3 S =r 3 ^ ft CTQ pd P rt H "CI 3 W 3 O O &- '^ p P3 f^ 2 3 O o C H & C B 2. "^ W !^- 3 ^ o 2 > S ^ t-i j-^. cr n! fi' p p *-* O 3 P. > qq p :^ rj;. P- Id o ^ ►a o W ^ C^ Z n o P d >< 2 3 3^ (73 H ro O > CL w g 5 a < S c p Z O n 3 o ~ p & > O P O HH f D- c > u> o en f3 ni CAl o 3 c 3" > O 2 H O C en P O O ?^ CA c O 1/. '-d r 1^ c-a g > 5' 3 W o p 3 --1 o p o 2. g APPENDICITIS. 261 iliac fossae, and blood and mucus are passed per rectum. In obstruc- tion the pulse is but little higher than normal until peritonitis occurs, while in appendicitis there is a gradual rise of pulse and temperature from the beginning. The early nausea and vomiting of obstruction recur so frequently as to become the most prominent symptom. The bowels cannot be moved nor can flatus be passed, and the abdominal distention occurs in greater degree, as well as much earlier, than in appendicitis. In appendicitis vomiting occurs quite early, is never stercoraceous, does not recur until peritonitis sets in, and constipation is never absolute. Typhoid Fever. — In the first two weeks of certain cases of typhoid there is rigidity and tenderness of the right iliac region, accompanied by fever. In the absence of a good previous history such cases are apt to impress one as being an appendicitis. As a rule, however, a differentiation is possible. The pain and rigidity are never as marked in typhoid as in appendicitis; the pulse is out of proportion too, being much slower than in appendicitis. In addition, there is a leukocytosis in appendicitis and a leukopenia in typhoid. The Widal reaction is characteristic of typhoid and is absent in appendicitis unless the patient has had a previous attack of typhoid. If a history can be obtained, it reveals the fact that the disease has been gradual in onset, accompanied by headache, backache, lassitude, and often by epistaxis. The enlarge- ment of the spleen and the steady rise of temperature with a relatively low pulse-rate are characteristic of typhoid. The differential diagnosis between typhoid perforation and appen- dicitis is referred to on page 269. Gastric Ulcer. — This is usually preceded by a history of long-contin- ued pains referred to some particular spot in the epigastrium, increased by the taking of food and often accompanied by hematemesis or melena. The majority of gastric ulcers occur in young women who are anemic and have had sedentary occupations. The examination of the stomach contents shows an increased amount of hydrochloric acid. Duodenal Ulcer. — There is a history of long duration of pain, oc- curring in middle-aged men, -two or three hours after eating. The pain is felt in the epigastrium, but may be referred to the shoulder or to the right iliac region. The principal diagnostic points of perforating gastric and duo- denal ulcers are discussed on pages 266 and 267. A perforating gastric ulcer can be diagnosed from the previous history, from the location of the pain, and from the presence of rigidity in the epigas- trium. The symptoms of collapse and the increase in pulse-rate are 262 THE ABDOMEN. much more marked than in appendicitis. The respiration is rapid and costal in type. In perforating duodenal ulcer the pain is not so typical in its location and is often referred to the right iliac region, but there is no rigidity in this location, as in an appendicitis. When, after the perforation of a gastric or duodenal ulcer, perito- nitis has occurred, and the septic fluid collects in the iliac fossa and pelvis, causing tenderness and rigidity, accompanied by abdominal distention, vomiting, increased pulse-rate, and leuko- cytosis, a differentia- tion from appendicitis is impossible, except from the previous his- tory. A cute Ch olecystitis . — The pain in this con- dition, whether due to gallstones or not, is localized in the right upper quadrant, as a rule, rather than in the right lower, as in ap- pendicitis. The pain is usually more cutting in character and radi- ates to the right shoul- der. Muscular rigid- ity and tenderness are most marked over the junction of the right rectus and the costal arch. There is often also a history of pre- vious attacks, accompanied, in some cases, by shght or marked jaundice (the latter if common-duct calcuK are present), early and repeated vomiting, and chills if an infection of the bile-passages has existed. In some cases a tender tumor, corresponding to the gallbladder, can be outlined by both percussion and palpation (Fig. 173). There are cases, such as those referred to later, where a differentiation between cholecystitis and appendicitis is impossible. These are where the gallbladder is at a lower level than normal. If Fig. 173. — Localized Pain and Rigidity in Normally Located AND Displaced Gallbladder. N, Normal position of gallbladder and liver; the black arrow indicates the most frequent direction of radiation of pain to the right shoulder; H, location of pain, etc., in descended Uver; E, ensiform process; GP, location of pain and rigidity in abscesses of the left lobe of the liver. APPEXDICTIS. 263 due to an elongated Riedel's lobe (Fig. 162), the resistant mass of liver tissue can often be felt through the thin and flabby abdominal walls. Similarly, one can outline a descended liver in some cases (Fig. 173). If pus form in the gallbladder (empyema), the rigidity and tender- ness are higher up than in appendicitis. However, leukocytosis and the existence of a tender mass in the right upper quadrant may lead to some confusion with appendicitis complicated by abscess formation in an appendix located high up (Fig. 171). Acute Inflammation of the Female Adnexa. — This can be best under- stood by a reference to the follo^nng table: Acute Appendicitis. Acute Salpixgooophoritis. 1. Muscular rigidity marked. i. But little rigidity. 2. Pain begins at umbilicus and becomes 2. Pain lower down in abdomen just above localized over McBurney's point Poupart's ligament, unless appendix points to pelvis. 3. Tenderness over right iliac fossa. 3. Tenderness low down over pehds. 4. Pain followed in a few hours by nausea 4. Nausea and vomiting infrequent. and vomiting. 5. Bimanual examination negative unless 5. Bimanual examination shows tender mass appendix in pelvis, then tender mass lateral to or behind uterus, lateral to uterus. 6. No history of gonorrheal infection. 6. Usually history of infection to be obtained. When acute appendicitis occurs during the course of an acute inflammation of the female pelvic organs, a differentiation is impossible, except that the pain is most intense over ]\IcBumey's point. Other conditions from which appendicitis must be differentiated are: 1. Renal and ureteral coKc (page 270). 2. Pyonephrosis (page 252). 3. Pelvic inflammatory conditions in women. 4. Acute pancreatitis (page 270). 5. "Twisted pedicles of ovarian and uterine tumors (page 273). 6. Abdominal crises due to ^leckel's diverticulum (page 279). 7. Torsion of the spermatic cord of a normal or undescended testis (page 274). 8. Inflammation of the intraabdominal portion of the vas deferens (page 276). 9. Embolism and thrombosis of the mesenteric vessels (page 272). 10. Acute pleural or pulmonary inflammation (page 276). 11. Dietl's crises due to the kinking of the ureter in movable Iddney (page 271). 264 THE ABDOMEN. 2. GALLSTONE COLIC. One of the most frequent acute abdominal conditions is that \Yhich is due to biliar)' calcuH. Diagnosis. — Paiti and Tenderness. — This is of an excruciating character, exceeding in severity that due to ahnost even.' other acute abdominal condition. It is the result of two factors. The first of these is the acute cholecystitis resulting from infection. This pain of the acute cholecystitis is less severe than the second, or pain due to the muscular spasm of the cystic or common duct. This second factor is the chief cause of the pain in bilian- colic. The pain is felt in the right hypochondrium and epigastrium, radiat- ing usually to the right and rarely to the left shoulder. In some cases the pain radiates toward the right ihac region, simulating that of appen- dicitis. The entire region between the right costal arch and umbilicus is extremely sensitive to pressure during the attack. If the hver is at a lower level or there is an elongated Riedel lobe, the pain, tenderness, and rigidity may be at the level of the umbihcus or even in the right iliac region itself. Muscular Rigidity. — This is most marked in the right hypochon- drium, but may be at a lower level if the gallbladder is in an abnormal position (see Fig. 173). Vomiting. — This is an early symptom, consisting at first of mucus, later of bile. It is present almost from the moment of the onset of the pain and recurs frequently during the attack. Jaundice. — If present at all, it occurs only to a shght degree, in the majority of cases of gallstone coUc, due to the passage of a calculus through the cystic duct. Often it can be best seen in the sclerae and on the roof of the mouth. When present in marked degree it signifies the passage of a stone through the common duct. Fever. — In the majority of cases there is a rise of temperature in gallstone colic, due to the accompanying cholecystitis. If the tempera- ture and other inflammatory symptoms continue after the pain has subsided, an empyema of the gallbladder is to be suspected. If the gallstone colic is accompanied by repeated chills, followed by a marked rise of temperature and a sweat, there is probably a complicating cholangitis. The finding of gallstones in the stools is, of course, positive evidence of the attack having been one of bihar}' colic. Differential Diagnosis. — Acute Cholecystitis. — Acute inflammation GALLSTONE COLIC. 265 of the gallbladder due to causes other than calculi produces less severe pain than a biliary colic. The abdominal rigidity and tenderness is not so marked, so that the enlarged gallbladder can often be outlined by percussion and palpation. There is, however, no means of distin- guishing absolutely a cholecystitis due to calculi and one not due to a simple infection or a catarrhal condition. In the majority of cases it is the result of calculi. Renal Colic. — In renal colic the pain usually begins in the back over the kidney and radiates down the ureter toward the testis and thigh of the same side. The kidney is tender on palpation and the urine contains blood and often pus, but is free from bile. Appendicitis. — There is no initial rise of temperature, the latter usually appearing after a few hours. The vomiting in biliary colic immediately follows the onset, and not after a few hours, as in appen- dicitis. It is also more frequent during the continuance of the pain in biliarv- colic. The pain in the latter is more severe than in appendicitis, is located higher in the abdomen, as a rule, and radiates to the right shoulder. The muscular rigidity and tenderness are also higher, being most marked just beneath the costal arch. Appendicitis and cholelithiasis at times coexist, so that the clinical picture is a most confusing one. DietVs Crises and Floating Kidney. — A floating kidney may cause biliary colic, jaundice, and vomiting; symptoms of compression of the portal vein usually coexist. K diagnosis can be made only if the symptoms cease when the kidney has been felt and is replaced. Attacks of severe colic, nausea, and vomiting may occur when the ureter is kinked, through the sudden descent of a movable kidney. The differentiation from gallstones may be made from the fact that the pain radiates along the ureter and the kidney is tender and swollen for some hours after the attack. Often its cessation is followed by a largely increased urinary flow. Gastric and Duodenal Ulcers.- — The pain of a gastric or duodenal ulcer is never as severe as that of biliary colic and it can be more accur- ately localized in the epigastrium. It begins soon after eating in the case of gastric, and two to three hours later, in that of duodenal ulcer. There is no rigidity or tenderness over the right hypochondrium and no rise of temperature. 266 THE ABDOMEN. 3. PERFORATIONS OF ULCERS OF THE STOMACH OR DUODENUM. The diagnosis of perforations of ulcers in these viscera can be made in the first twelve hours if the previous history is considered in connec- tion vvnth the acute symptoms. In 90 per cent, of perforating gastric ulcers there is a history of symptoms referable to ulcer of the stomach or duodenum, according to Brunner.^ Perforating gastric ulcer is more frequent in women (4 to i), while perforating duodenal ulcer occurs oftener in men (10 to i). Duodenal ulcer perforates twice as often as gastric ulcer. The symptoms in the majority of cases are so typical that a diag- nosis can be made from the following symptoms, taken in conjunction with the previous history: Pain. — In over 95 per cent, of the cases the pain occurs suddenly and is very severe and stabbing in character, so that the patients cry out, drawing up their limbs, and often become faint. The pain is at first localized by the patient in the epigastrium, but later it becomes more diffuse. The point of greatest tenderness in five-sixths of the cases of gastric ulcer corresponds to the point of spontaneous or subjective pain; w^hile in duodenal ulcer the tenderness is in the right iliac fossa in the majority of cases. Muscular Rigidity. — This symptom, as in perforations of other viscera, is, when associated with pain, of great diagnostic importance. As elsewhere explained, it can be found by passing the fingers lightly over the abdomen and not by violently prodding. The abdomen is board-hke and often retracted until, after six to twelve hours, the tym- pany, due to beginning peritonitis, causes it to become gradually dis- tended. Vomiting. — This occurs in about one-third of the cases, and, as in appendicitis, if associated with pain and rigidity is of great diagnostic value. Vomiting which occurs after the first twenty-four hours is usually indicative of peritonitis. Vomiting, as an early sign, follows perforations of duodenal ulcers far more constantly than that of gastric ulcers. Obliteration of Liver Dullness. — This symptom is so inconstant that but little reliance can be placed upon its presence or absence. Liver dullness is apt to be diminished or absent through tympanites, so that the sign is of little value. If the abdomen is not distended and there is no liver dullness to be found, it is of value taken in conjunction with the localized pain, rigidity, tenderness, and vomiting. ^ "Deutsche Zeitschrift f. Chirurgic," Bd. Ixix. PERFORATIONS OF ULCERS OF THE STOMACH OR DUODENUM. 267 Dullness in the Flanks and Right Iliac Region. — A shifting area of dullness found in the flanks within the first twelve to twenty-four hours is of value as indicating free fluid. Even this symptom is apt to be misleading, and, as in the case of the above symptoms, too much reli- ance should not be placed upon it, owing to the fact that intestinal coils filled with fluid feces may give the same signs. Pulse. — This remains unchanged in many cases until peritonitis begins, when it gradually becomes more rapid and jerky. In other cases it is rapid, feeble, and irregular from the beginning. Respiration and Fades. — From the moment of perforation the breathing is almost entirely costal, shallow, and quick, in the effort to avoid movement of the upper abdominal regions. The face and extremities are, in the majority of cases, pale, cold, and clammy; the eyes sunken and the expression of the face one of great anxiety.^ Differential Diagnosis between Perforation of Gastric and of Duodenal Ulcer. — In deciding whether the perforation is due to a gastric or duodenal ulcer, the following facts must be taken into con- sideration. The majority of cases of duodenal perforation occur in men, espe- cially alcoholics; the seat of the initial pain and point of greatest ten- derness is to the right of the median line; often the tenderness is most marked in the right iliac region. There is not nearly so frequently a previous history of preceding digestive disturbances as in gastric ulcer. A previous history of tarry stools and the occurrence of vomiting and pain a long time after eating, suggest duodenal ulcer. In perforation of a gastric ulcer, the spontaneous pain and area of greatest tenderness are almost always in the epigastrium. Gastric ulcers occur more often in women about the age of twenty, with a prior history of digestive disturbance, pain soon after eating, and not infrequently of hematemesis. It is almost impossible to accurately locate the exact seat of the gastric perforation. Differential Diagnosis between these Perforations and Other Acute Abdominal Conditions. — Perforations of the stomach from carcinoma, perforation of the gallbladder, and perforation of a tuber- culous ulcer of the intestine are so rare that they need only to be mentioned. Appendicitis. — This is the greatest source of error and is fully -considered on page 256. The pain in gastric ulcer perforations differs 'In subacute perforations, i. e., those occurring so slowly that a walling off is possi- ble, as first described by Moynihan, all of these symptoms are present, but in far less marked degree. 205 THE ABDOMEN. in its seat from that of appendicitis, while that of many cases of duodenal ulcer more nearly coincides with that of appendicitis in being situated in the right iliac region. In appendicitis the rigidity is more localized in the right iliac region, and there is seldom a history of digestive disturbances or of pain after eating or hemorrhage from the stomach or bowels. Gastralgia. — There are no objective symptoms. The pain is relieved by pressure, has been present on previous occasions, does not last as long, and occurs in neurotic persons. There is no history of hematemesis or of melena. Angina Sclerotica Abdominis. — This relatively rare condition has been mistaken for perforation. In both there is sudden onset of pain, quick pulse, and collapse, but in angina the pain is higher and passes off more quickly. Gallstone Colic. — The pain is less severe and not so sudden, is conjSned to the gallbladder region, radiates to the right shoulder, there are often chills and rise of temperature. The colic attacks pass away or the pain is intermittent. The gallbladder can often be palpated and there is often a previous history of similar attacks. The other conditions from which these perforations must be differentiated are discussed elsewhere in this chapter. They are: Acute pancreatitis (page 270); thoracic affections (page 276); embohsm and thrombosis of the mesenteric artery (page 272), etc., lead poisoning, renal cohc, and torsion of abdominal tumors. TYPHOID PERFORATION. Perforations of typhoid ulcer usually occur in the third week of the disease. The diagnosis in the majority of cases can be made by careful observation of a sudden change in the patient's condition, accompanied by sharp pain in the right ihac region, muscular rigidity, tenderness, and a sudden rise in pulse-rate and respiration. In patients who are apathetic all of these symptoms are apt to be overlooked, and the first signs which will call attention to the possibihty of a perforation are the change in the expression of the face, rigidity and tenderness of the abdomen, gradually becoming diffuse, the rise in pulse-rate and the appearance of tympanites. The same may be said to be true for typhoid perforations in children where collapse, severe abdominal pain, uncontrollable vomiting, ten- derness, and distention are all much less marked than in adults. Another condition which may prevent making an early diagnosis in PERFOILA.TIOXS OF ULCERS OF THE STOMACH OR DUODENUM. 269 typhoid perforation is to be found in the distention of the abdomen which not infrequently accompanies the more severe cases. If a diagnosis of perforation has not been made from the charac- teristic pain, muscular rigidity, and tenderness of the right ihac region, accompanied by an increased pulse-rate, fall of temperature and collapse, then a diagnosis must be made from the S}Tiiptoms of beginning perito- nitis. These are, in such cases, general abdominal tenderness and rigidity, repeated vomiting, and gradually increasing abdominal dis- tention, if the latter has not existed before the onset of the pain. The loss of liver dullness is so inconstant a symptom as to be of little value in making a diagnosis of perforation. In many cases the blood-count may be of aid, frequently the normal leukopenia of typhoid being replaced by a gradually increasing leukocytosis. Differential Diagnosis. — Hemorrhage. — The symptoms of hem- orrhage from a typhoid ulcer of the ileum may simulate those of per- foration and the two may coexist. Both produce symptoms of collapse, such as sweats, rapid pulse and respiration, sunken eyes, etc. But hemorrhage is not attended by such marked pain, tenderness, or rigidity in the right ihac region, and" in an hour or two blood is passed with the bowel movement. If there is no reaction from the collapse symptoms, and abdominal tenderness, rigidity, and distention begin to appear, the case should be looked upon as one of perforation, either accom- panied by or independent of hemorrhage, as the case may be. Appendicitis. — Vomiting is more apt to accompany the initial pain in appendicitis, and there is not apt to be such an amount of collapse in the early hours of an attack as is the case in intestinal perforation. Cholecystitis. — This usually occurs at a somewhat earlier period in the course of typhoid than does a perforation, and is accompanied by the characteristic pain, muscular rigidity, and tenderness just below the costal arch, and not over the right ihac region. There is also at times a mass to be palpated or dullness to be elicited at an early stage. Suppurating Mesenteric Glands. — Every case described during the past few years of suppuration and rupture of the mesenteric glands occurring during typhoid and simulating perforation, has had symptoms of pain, collapse, rapid pulse, etc. The muscular rigidity, however, is not so well localized, as a rule, in the right ihac region, nor are general abdominal tenderness and distention so hkely to follow, as in genuine typhoid perforation. 270 THE ABDOMEN. ■ 4. ACUTE PANCREATITIS. The occurrence of sudden severe pain in the epigastrium, accom- panied by symptoms of collapse and by vomiting, should lead one to diagnose an acute pancreatitis, if the other acute conditions which occur in the upper abdominal region can be excluded. In addition to the above triad of symptoms, there is muscular rigidity and tenderness over the epigastrium, and when in two or three days this subsides somewhat, a tender mass can be felt here. If sup- puration occurs a rise of temperature persists after the subsidence of the acute symptoms, and with it a leukocytosis. In many cases, how- ever, death occurs on the second to fourth day of the disease. In the acute cases there is marked constipation, but this is not so absolute but that flatus can be passed by the aid of an enema. There is also fat in large quantities in the stools. There is a subacute form in which the symptoms are all less violent. There is a constant dull epigastric pain, loss of flesh, and the vomiting is less severe. There is diarrhea instead of constipation, pus and blood appearing in the fetid stools." If an abscess has developed there is a very tender epigastric tumor accompanied by chills and fever. Differential Diagnosis. — Biliary Co/fc— The symptoms of this at times precede those of acute pancreatitis in many cases. Phlegmonous Gastritis. — This is a rare condition, but very acute and fatal. The symptoms are very much the same as those of an acute pancreatitis, but the pain is not as severe; there is high fever and early signs of general peritonitis. The onset is more gradual and the vomitus contains pus and blood. 5. RENAL COLIC. Symptoms. — In a typical case the pain is intense, causes faintness and collapse symptoms, such as feeble, rapid pulse, cold, clammy skin and extremities. The pain is paroxysmal and begins usually in the back over the kidney, radiating along the ureter to the testis or labia and thigh. At the onset, in addition to the pain and collapse, there is often a chill and vomiting. The attack may last three to five days and then suddenly subside. The urine during the attacks contains blood, which can at times only be found by the aid of the microscope. Frequency of micturition accompanies the attacks. The passage of the calculus during or dietl's crises. 271 shortly after the attack is confirmatory evidence. Should the calculus slip back, or should the attack be due to a twisted ureter, an unusual amount of urine often follows the subsidence of the pain. The diagnosis of atypical cases of renal coKc and the diagnosis of renal calculus in general are discussed on page 365- 6. DIETL'S CRISES. These are attacks of acute abdominal pain, first described by von Dietl of Vienna, accompanied by nausea, a chill, and vomit- ing which are the result of the kinking or bending upon itself of the ureter in movable kidney (Fig. 174). The pain may be quite severe and usually radiates along the ureter, as in renal colic. During the attack the kidney is sw^ollen and tender, this condition last- ing several hours. In some cases a distinct hydrone- phrosis develops during the attacks. Blood is present in the urine only after the attack has sub- sided, and is accompanied by polyuria, while during the attack there is diminished secretion of urine. The diagnosis may be made from the palpation of the swollen, tender, displaced kidney, and the fact that when it is replaced the symptoms cease. ^ There is but little abdominal rigidity, no fever or leukocytosis, and the condition occurs most frequently in muciparous women. Differential Diagnosis. — Renal Colic Due to Calculi. — In renal colic due to calculi the symptoms of pain radiating along the ureter, Fig. 174. — Lateral View of Relations in Intermittent Hydronephrosis Occurring in a Floating Kidney, Due to Kinking of the Ureter. H, Enlarged kidney. Note the kinking of the ureter. (This is the cause of the symptoms in Dietl's crises.) 272 THE ABDOMEN. nausea, vomiting, etc., are the same as in Dietl's crises. The pain, how- ever, is much more severe and apt to be accompanied by symptoms of collapse, such as cold, clammy sweat, rapid pulse, etc. There is also blood in the urine during the attacks, while in kinking of the ureter it is only present at the end of the attacks. If, however, the attacks of kinking of the ureter follow in rapid succession, blood is found in the urine all of the time and a differentiation is very difficult. Renal coHc is less apt to be accompanied by enlarge- ment of the kidney. Gallstones. — The pain is located higher up in the abdomen, is much more severe, and there is rigidity and tenderness over the region of the gallbladder. The pains radiate to the shoulder. If the patient is laid on the left side, the movable kidney can be more distinctly palpated because the gallbladder rolls away. Fig. 175. — Prominence of Abdomen as Result of Tympanites following Thrombosis of the Superior Mesenteric Artery in a Woman with a Pendulous Abdomen. 7. EMBOLISM AND THROMBOSIS OF THE MESENTERIC VESSELS. An acute abdominal condition which is far more frequent than was formerly thought follows the occlusion of the mesenteric vessels (Fig. 176). Clinically it is impossible to distinguish embolism of the superior or inferior mesenteric artery from thrombosis of the mesenteric veins. Both conditions produce, as a rule, very acute symptoms. In some cases they resemble those of intestinal obstruction; in another class of cases, peritonitis is simulated. Embolism occurs in both sexes after middle life, secondary to endo- TORSION OF THE PEDICLES OF OVARIAN AND UTERINE TUMORS. 273 carditis or to atheroma of the mesenteric vessels. Thrombosis may be primary, following acute infective processes, especially of the appendix. It may occur secondary to any hepatic condition which causes portal stasis. In but few cases has it been possible to make a diagnosis, nor is this absolutely necessary, since the symptoms are so acute that an explor- atory laparotomy is indicated, even if a probable diagnosis has only been made. The disease begins in one of two ways, (a) Symptoms which sim- ulate intestinal obstruction, with or without peritonitis. This form begins with colicky abdominal pain followed by nausea or vomiting and absolute constipation, so that not even flatus is passed. The abdomen soon becomes so distended, rigid, and tender that examina- tion becomes very difficult (Fig. 175). (b) Symptoms of hemorrhage from the intestine. In this form the symptoms of early bowel paralysis are not so marked, but there is great prostration, severe colicky pain, and frequent bloody stools. Differential Diagnosis. — This is impossible in the majority of cases, except that embolism occurs after middle life. It must be differentiated from perforations of gastric and duodenal ulcers, from acute cholecystitis (page 266), appendicitis (page 256), etc., and the various forms of intestinal obstruction. 8. TORSION OF THE PEDICLES OF OVARIAN AND UTERINE TUMORS. The presence of such a tumor may reveal itself for the first time when the pedicle has become twisted. The onset is sudden, with severe colicky pain referred to the pelvis, accompanied by vomiting and shght muscular rigidity. If the tumor becomes gangrenous, these primary symptoms are rapidly followed by those of a spreading peritonitis. The rigidity and tenderness, which were at first present in only the lower part of the abdomen, become general. The pulse-rate increases rapidly and abdominal distention becomes marked, and the patient septic. The diagnosis may be made by a pelvic examination and the palpa- tion of the tumor mass and its pedicle. Without the use of an anes- thetic, such examination can only be made with difficulty, owing to the muscular rigidity. In some cases a history of gradual enlargement of the abdomen, preceding the acute attack, can be obtained. After a septic paralysis of the bowels has occurred, the case cannot be differentiated from peritonitis due to other causes, unless the vaginal examination shows the presence of a tumor and its pedicle. 2 74 THE ABDOMEN. Differential Diagnosis. — Appendicitis. — In the early hours, if the tumor is located on the right side, there may be some resemblance. The palpation of a tumor will, however, at once exclude an appendicitis, since such a large inflammatory mass does not form in so short a time. Later on such a mass may resemble appendicitis with abscess formation, but the tumor is more elastic and there is more general abdominal rigidity and tenderness, as well as other symptoms of a spreading peri- tonitis. 9. TORSION OF THE SPERMATIC CORD. This may occur in an imperfectly or in a normally descended testis (Fig. 232). It usually follows heavy lifting, etc. The onset is very sudden, greatly resembling that of a strangulated hernia. The attack begins with severe pain in the region of the testis, far greater than in an ordinary epididymitis, accompanied by collapse, vomiting, constipation, great local tenderness, and swelling. The principal condition from which it must be differentiated is a strangulated hernia. This is as follows (Eccles) : Torsion of Cord. Strangulated Hernia. History Probable of strain. Often of strain. Position of testis Often imperfectly descended. Usually fully descended. Shock Moderate. Often severe. Vomiting Slight and not persistent. Severe and persistent. Constipation May be present. Is absolute. Tenseness of swelling Not marked. Marked. Impulse on coughing None. None. Condition of cord Tender, twisted, and swollen. Not to be felt. 10. VISCERAL CRISES. These may occur either as a complication of tabes or of an angioneu- rotic edema. Those due to tabes may at times be so severe as to fully simulate some of the previously named acute conditions, such as appendicitis, perforation of ulcers, gallstone colic, or even intestinal obstruction. In patients at or above middle age, especially males, who have such symptoms, the possibility of visceral crises of tabes must not be over- looked, and other evidences of the disease searched for. In the most typical cases there are severe epigastric pains, repeated vomiting, great prostration, and rapid pulse. The attack may ter- minate fatally in a short time, or continue for several hours or even for days and recur from time to time. VISCERAL CRISES. 275 Crises are also associated with various manifestations of skin affections of the erythema group, and with attacks of angioneurotic edema. There is severe abdominal pain which may last for hours. One case, described by Osier,' was mistaken for renal coHc. The pain Fig. 176.— Gangrene of a Single Loop of Small Intestine Due to Eslbolism of Mesenteric Artery (Kenerson). is sometimes accompanied by nausea and vomiting, in other cases by diarrhea, and in still others by the passage of blood. - The diagnosis can only be made from the history of the cutaneous affections or of repeated attacks of sudden edematous swelling in various parts of the body. '"American Jour. :Med. Sciences," Jan. i, 1904. 276 THE ABDOMEN. n. ANGINA SCLEROTICA ABDOMINIS. This occurs in elderly people in the form of attacks of severe pain in the epigastrium. It is due to an atheromatous condition of the vessels of the splanchnic area and must be differentiated from lead colic and from the crises of tabes. The attacks may be accompanied by diarrhea. The stool at times contains large quantities of blood. 12. REFERRED PAIN FROM SPINAL AND THORACIC CONDITIONS. Spondylitis, and tumors of the spinal cord, of its membranes, or of the vertebra, may cause severe abdominal pain, which is referred to the terminal filaments of the spinal ner\'es of the corresponding segment in the abdominal wall. The pain is seldom as acute as in true abdom- inal affections, and is not accompanied by muscular rigidity or tender- ness. Examination of the spine for evidences of spond^^Htis (page 684) will soon reveal the nature of the referred pain. Examination of the nen'ous system and the history of the case will eliminate tumors of the cord or spinal column. Thoracic Conditions. — Cases of both pneumonia and pleurisy occur, in which there is complaint of severe pain in the abdomen at the onset of the disease. This is especially true in children. There may be rigidity of the abdominal muscles on the side affected. In pneu- monia there is a history of a chill. The acute onset is followed by dyspnea, and marked increase in respirations and pulse-rate. The pain is seldom as well locahzed as in the acute abdominal conditions, nor is the muscular rigidity as circumscribed and constant. There is one form of pleurisy (diaphragmatic) which simulates acute abdominal affections very closely. The breathing is shallow and costal, the pain is severe and referred to the upper abdominal region, as in perforations of gastric and duodenal ulcer, acute pancrea- titis, etc. Objectively but little can be found and a differential diagnosis is difficult in the early hours. The case should be watched for several hours before a final diagnosis is made. 13. INFLAMMATION OF THE INTRAABDOMINAL PORTION OF THE VAS DEFERENS. Severe pain, of a coHcky nature, referred either to the right or left iUac regions is the initial s}Tnptom. It is later accompanied by nausea or vomiting, as a forerunner of epididymitis or orchitis. ACUTE INTESTINAL OBSTRUCTION. 277 When this condition exists on the right side, it may be mistaken for an appendicitis. Especially when it precedes the orchitis of mumps, one must avoid this error. In gonorrheal cases, the diagnosis may be made from the urethral discharge, which often ceases suddenly before such an attack. When it follows mumps, the previous history is of value. The most tender point is not over the middle of the right iliac region (McBumey's point), as in appendicitis, but is deeply situated over the middle of Poupart's ligament or deep down in the pelvis. Rectal examination is of great aid in making a differentiation. Group III. — Early Signs of Intestinal Obstruction. ACUTE INTESTINAL OBSTRUCTION (ILEUS). In every case before a definite diagnosis of intestinal obstruction is made three points must be considered: 1. What symptoms indicate intestinal obstruction? 2. What is the probable nature and seat of the obstruction? 3. What other symptoms might simulate it? I. Symptoms of Intestinal Obstruction. — The most typical ones are: (a) Absolute constipation. (&) Constantly recurring vomiting finally becoming fecal. (c) Pain of varying intensity and location. (d) Gradual or sudden distention of the abdomen. (e) Gradually increasing pulse-rate. (/) Visible peristalsis and the presence of a tumor. (g) Collapse symptoms, such as sunken eyes, anxious face, cyanosis, pallor, dyspnea. // a patient, suffering jrom a sudden attack oj abdominal pain, lias constantly recurring vomiting, and every effort to secure the passage of feces or flatus results negatively, a diagnosis of intestinal obstruction may be made. The three symptoms common to all forms of abdominal obstruc- tion are: 1. Absolute inability to secure the passage of feces or flatus. 2. Vomiting first of mucus, then of bile, and lastly of fecal matter. 3. Pain. Constipation is often the first symptom. Before declaring it abso- lute, however, high rectal enemata should be given, with the patient lying on his back with hips elevated. The fountain syringe or irrigator 278 THE ABDOMEN. does not need to be raised more than three feet above the patient. An ordinary high rectal tube is inserted almost its full length, the fluid being allowed to run through the tube during its insertion into the rectum. The temperature of the liquid should never be above 110° F. and the quantity used should not exceed two quarts in adults and one and one-half pints in children. To test the passage of flatus most accurately it is best to keep the outer end of the tube under water and thus observe the escape of bubbles of gas as they leave the tube. If no morphin has been given, and all the fecal matter below the obstruction has been washed out, and there is no escape of flatus or feces on repeating the enema, the conclusion can be drawn that some obstruction either of adynamic or mechanical nature exists. The only exception to the statement that absolute constipation is one of the most important diagnostic signs of intestinal obstruction occurs in those cases of intussusception in which sufficient lumen remains in the center of the invaginated gut to permit the passage of frequent liquid fecal stools. The diagnosis in such cases must be made from the other special signs of intussusception, referred to below. Vomiting. — The most characteristic emesis is that occurring either with or independently of pain, but so frequently repeated that nothing is retained. Fecal vomiting does not usually appear until the third or fourth day. Therefore a diagnosis must be made at an earlier period to be of value in saving the patient's hfe by operation. The vomiting which accompanies the pain of other acute abdominal affections, such as appendicitis, is primary, i. e., it occurs perhaps once or twice within the first few hours after the onset of pain, but is not frequently repeated unless peritonitis sets in. In intestinal obstruction the emesis begins rather innocently at first, as in the affections of Group II, but constantly recurs, so that anything which is swallowed remains in the stomach but a short time. The vomitus is at first composed of the food ingested before the attack began, mixed with mucus. Later it consists of the bihous vomit, so frequently seen in acute gastroenteritis, though more fre- quently repeated than in the latter. After a variable time, usually the third to fourth day, it becomes of a brownish-black color and of fecal odor. Emesis is then almost constant. Pain as a diagnostic sign varies greatly. It is most marked in ob- struction due to volvulus, to bands, or to protrusion through external or internal hernial apertures. There are cases in which but httle pain is present and the diagnosis ACUTE INTESTINAL OBSTRUCTION. 279 must be made from the absolute constipation, constant vomiting, and gradually increasing tympanites. The pain is at first sharp and colicky in character. Later it becomes more or less continuous, until, the paralysis having become complete on the third or fourth day, pain ceases. A gradually increasing distention of the abdomen is characteristic of intestinal obstruction. Its distribution over the abdomen varies according to the seat of the obstruction, and is referred to in detail later. The pulse-rate does not, as a rule, increase as steadily as in peritonitis. In some forms of obstruction, however, such as intussus- ception, the pulse-rate is rapid and weak from the beginning. Peristaltic waves may, at times, be seen traveling in an opposite direction from the normal during the first forty-eight to seventy-two hours. This is to be seen quite easily before the abdominal distention is too great, provided there is not too much fat in the abdominal wall. A tumor is palpable in many cases in which the acute symptoms follow those of chronic stenosis of the bowel, of long duration. It can also be felt in cases of intussusception along the transverse colon, in the left iliac fossa, or per rectum. The symptoms of collapse appear gradually in the majority of cases, usually about the third or fourth day. Rarely, they appear suddenly, at an earlier period, in cases of volvulus. Probable Nature and Seat of the Obstruction. — Every patient should be examined before operation to ascertain these facts. Such examination should include: (a) The previous history. (b) The physical examination of the abdomen itself. (c) Rectal and vaginal examination. Strangulation. History. — Strangulation most frequently occurs in adults who have a previous history of attacks of abdominal pain, a previous attack of peritonitis, an operation on the abdominal viscera, or a recognized hernia. The previous history may, however, throw absolutely no light on the present condition, especially in those cases in which strangulation by bands derived from Meckel's diverticulum occurs. The previous existence of a hernia is of value, since strangulation of only a portion or the whole of a coil of intestine (acute partial enterocele) may give rise to the same symptoms as though the entire lumen of the gut were obstructed. Abdominal Pain. — This is usually quite severe and of a colicky 28o THE ABDOMEN. nature. In the case of strangulated hernia it is most marked in close proximity to the hernial opening. Nausea and Vomiting. — These occur quite early and are more marked in this form of intestinal obstruction than in any other except volvulus. Vomiting becomes fecal from the third to the fifth day. Constipation. — This is absolute in strangulation. Enemata given in the early hours bring away some fecal matter; after this they result negatively. Shock. — This is quite marked, as a rule, although it may not appear until the second or third day of the obstruction. Examination of Abdomen. — The distention of the abdomen appears quite early, being especially marked in the central portions of the abdomen if the small intestine is involved, and in the lateral portions if the large intestine is obstructed. Peristalsis may be seen in the early hours, through a thin abdominal wall. It can often be artificially elicited by light tapping on the abdominal wall. Volvulus. This can rarely be diagnosed before operation. Previous History. — It occurs most often in adults, especially those suffering from chronic constipation. At times there is a history of previous attacks of peritonitis. Pain. — Pain is often severe from the beginning, and in some cases quite accurately localized to the left of the umbihcus. It is very severe and colicky in nature. Nausea and Vomiting. — These do not occur as early as in strangu- lation and the vomitus becomes fecal on the third or fourth day. Constipation. — This is more marked at an early period than in any of the other forms of obstruction, owing to the fact that the large intes- tine is involved. Shock. — -This does not occur as early as in strangulation or intus- susception, but may come on quite suddenly on the third or fourth day, and be extreme in character. Examination of Abdomen. — Visible, peristalsis may, at times, be seen on the left side of the abdomen, beginning at the point of obstruction and traveling upward and downward along the line of the transverse colon. The distention of the abdomen is much more extensive than in obstruction of the small intestine by strangulation. It is especially marked along the lateral aspects of the abdomen, often being horseshoe in outline, corresponding to the course of the colon. ACUTE INTESTINAL OBSTRUCTION. 281 Intussusception. The following are the most characteristic diagnostic points of intus- susception, according to Hess, who has collected them from 1028 cases. Vermiform Appendix \ Ilei ^■«bK Beginning of invagination in ileum. Fig. 177. — Intussusception. The illustration was made from a specimen of intussusception in an adult, in which the clinical picture was that of an appendicitis. It is of the iliac variety, in wliich one portion of the ileum has been invaginatcd into the other, the latter representing that portion of the ileum which is in close proximity to the ileocecal valve. The difference in color of the invaginated mucous membrane, which was deeply congested and hemorrhagic, is well shown. Previous History. — There may be a history of some intestinal disturbances, rarely one of abdominal trauma, but in the majority of cases the first symptoms appear very suddenly. Abdominal Pain. — First symptom without premonition, colicky in 252 THE ABDOMEN. character, uninterrupted at onset, later intermittent. In children in- ability to localize it. Nausea and Vomiting. — Nausea and vomiting occur either sim- ultaneously with the pain or immediately after. May be continuous or occur at intervals. Evacuations of the Bowels. — In acute cases we usually have one or more evacuations of fecal matter. After this, if occlusion is complete, there is complete absence of the passage of fecal matter and flatus. Hemorrhagic evacuation is one of the most constant symptoms of invagination. It varies from a few streaks to a profuse hemorrhage, which may cause death. Prostration. — Prostration is sudden in development and out of proportion to the other symptoms present. Tumor. — This is the most important physical sign from the diag- nostic standpoint. In 197 cases in which there is a complete history, 183 gave the history of the presence of an abdominal tumor. The presence of a rectal tumor was noted in 35 cases and an absence of same in 38 cases. The most frequent seat of the tumor is the region of the sigmoid flexure. The tumor is relatively very movable. Meteorism.—^leteorisui is usually slow in development and its absence is of diagnostic import. It depends upon the degree and seat of the obstruction. Tenesmus. — Tenesmus is much more frequently present than is meteorism. It is especially severe in intussusception of the sigmoid and rectum. Condition of the Abdomen. — Characteristic symptoms or signs, recognizable on the abdomen superficially, are usually absent. Fever. — Fever occurs in about 40 per cent, of all cases of invagina- tion in which the symptom is mentioned. Its presence is to be expected when complications have taken place. Obstruction from Tumors or Foreign Bodies. History. — An obstruction from gallstones is to be suspected in elderly women, especially if there has been a history of prior attacks of gallstone colic. Obstruction from tumors can only be suspected if there is a previous history of gradual loss in weight, or if symptoms of chronic stenosis, hke those referred to on page 341, have been present for some time before the symptoms of complete obstruction occurred. The symptoms of obstruction from tumors or foreign bodies appear rather insidiously in adults, as compared with those due to strangula- ACUTE INTESTINAL OBSTRLXTION. 283 tion or volvulus. There is but little pain and abdominal distention is much more gradual in its onset. Pain and vomiting are not marked or severe, as a rule. The per- istalsis is very distinctly visible through the thin abdominal wall in this form of obstruction. The constipation is absolute, however. Rectal and vaginal examinations are of the greatest value in adults in this form of obstruction for the purpose of determining the presence or absence of impacted feces or the presence of a pelvic tumor which causes compression of the intestine. In this form of obstruction there may be apparent relief, consisting in the passage of feces and flatus, and then recurrence in the form of symptoms of absolute obstruction. Adynamic Ileus. A form of intestinal obstruction due to acute paralysis of the mus- cular fibers of the intestinal coats is called adynamic ileus. It may follow laparotomies, injuries of the spinal cord in the dorsal region (see page 668), or may appear without any apparent cause. It is not due to a septic paresis of the intestine, but the result of inhibition of nerve im- pulses. The diagnosis differs only in the history and absence of ob- jective findings from the other forms of obstruction. Differentiation. — The principal conditions from which acute intes- tinal obstruction must be differentiated are the various affections mentioned under Group II. It is often very difficult to differentiate acute ileus from a spreading or general peritonitis, after the occurrence of bowel paralysis in the latter condition, usually on the second or third day. This difficulty is due to the fact that in both there is absolute constipation, incessant vomiting, great prostration, and rapid pulse. There is, perhaps, less rigidity and less pain in these advanced cases of intestinal obstruction than in those of peritonitis. Of great diagnostic import -is the presence of a history pointing to an appendicitis or some similar condition, and of like importance is the finding of a strangulated hernia, or other causes of intestinal obstruction. In the early period, i. e., in the first twenty-four to thirty-six hours, the following difl'eren- tial points are of value : Acute Peritonitis. Acute Intestinal Obstruo TION. 1. Rigidity Uniform and marked. Not so marked. 2. Abdominal distention. Gradual. Rapid except in intussusception. 3. Visible peristalsis Not present. Often visible in early hours. 4. Pulse Gradual increase in frequency. Rapid increase in frequency. 5 . Vomiting Present at first but does not recur Incessant from beginning, be- until third day. coming fecal. 6. Constipation ..Some results from enemata in No result except in fecal im- early hours. paction. 284 THE ABDOMEN, Other conditions from which intestinal obstruction must be differen- tiated are: Acute Pancreatitis. — In this the constipation is not complete. Vom- iting never becomes fecal. The rigidity is confined to the upper half of the abdomen and the shock and severe pain in the epigastrium are present from the onset. Acute Enteritis. — In this there may be repeated vomiting and pain at the umbilicus; there is usually diarrhea present or it is possible to secure bowel movements by means of enemata. The pulse does not increase in frequency as the hours pass, except when the diarrhea is very copious. Abdominal rigidity is, as a rule, not present. Perforation of an Ulcer of the Stomach or Intestine. — As in pancrea- titis, the symptoms of shock and pain are more severe and sudden from the beginning. There is often a previous history of ulcer and the symptoms of peritonitis gradually develop. Thrombosis and Emholism of Mesenteric Artery. — The symptoms of this condition, when there is no blood passed with the bowel move- ment, resemble greatly those of acute obstruction, and it is impossible to make a diagnosis before operation, but the possibihty of embolism occurring in a person suffering from arteriosclerosis must be borne in mind. Aside from this, the histon,' will throw but little light on the diagnosis. The symptoms of paralysis of the gut in this condition are so rapid in their onset that it is impossible, in the majority of cases, to distin- guish between this condition and obstruction from mechanical or dyna- mic causes. Finally, it may be said that the diagnosis of intestinal obstruction often cannot be made at the first examination in the early hours. But the examination should be repeated from hour to hour, and if no bowxl movement has occurred or the enemata are unsuccessful, and the vomiting continues, accompanied by rise of pulse-rate and abdom- inal distention, no delay should be permitted in performing an explor- atory' laparotomy. Such an operation, delayed more than forty-eight hours, during which the patient is becoming toxic from the absorption of stercoraceous material and suffering from the shock of intestinal obstruction, usually proves fatal. Group IV. — Early Signs of Internal Hemorrhage. RUPTURED EXTRAUTERINE PREGNANCY. There is often a history of a long period of sterihty, followed by a partial or entire cessation of menses for one or more periods, and the ABDOMINAL TUMORS. 285 signs of pregnancy with expulsion of decidua per vaginam from time to time. The rupture of such a pregnancy may be diagnosed from the sudden onset of severe abdominal pain, accompanied by collapse, in a woman having the above history. The face and visible mucous membranes are very pale, there is great restlessness and thirst, repeated attacks of syncope, and a rapid, weak pulse. The abdomen is uniformly rigid and tender, but not as marked as in a peritoneal infection. Distention gradually increases and may become quite marked. Bimanual examination may reveal a tender mass lateral to the uterus or in the culdesac of Douglas. Abdominal Tumors. When we examine a patient with an abdominal tumor two questions present themselves: 1 . Which viscus is involved ? 2. What is the nature of the tumor? These two questions cannot be answered without careful consid- eration of all of the data at hand. These data are acquired as follows: 1. A detailed history is taken. 2. The great probability of tumors of certain viscera occurring in the corresponding locations. 3. The results obtained from an examination of the abdomen augmented by certain tests and procedures to be described. 1. History. — In considering the history one must not fail to note the age, habits, venereal history, prior illnesses, previous operations, gain or loss in weight, rapidity of enlargement of the abdomen, and any other symptoms accompanying the presence of the tumor. These are referred to again in connection with the individual forms of tumors. 2. Probabilities of Tumors of Certain Viscera Occurring in Corresponding Locations. — The normal location and other charac- teristics of each abdominal viscus must be borne in mind. This is of considerable aid in making a diagnosis, since in the case of any tumor we must first think whether it corresponds in location to some normal viscus. We can often identify certain tumors by their resemblance in outline, edge and consistency to such a normal viscus. This is espe- cially true at an early period of the development of the tumor. Many tumors of the gallbladder, liver, spleen, and kidney, corre- spond in both their position and shape to the normal organ (Fig. 178). ?86 THE ABDOMEX. An overdistended urinary bladder may be mistaken for an abdominal tumor unless the normal location and shape, when it is full, are remem- bered. It is not to be denied that certain organs, if situated in a part far away from their normal location, may be normal in size or be markedly altered and not be recognized as belonging to these viscera. Thus a normal-sized spleen may be displaced so as to lie in the right iliac fossa, or a kidney be located in the pelvis. These are excep- tional cases, and yet it is these ver}' unusual forms which render the diagnosis of ab- dominal tumors a dif- ficult problem which in many cases only an explorator}' lapa- rotomy solves. 3. The Results Obtained from the Abdominal Exam- ination and its Ad- juncts. — This should be undertaken in a systematic manner by the usual methods of physical diagnosis, es- pecially inspection, palpation, and percus- ^^"^^ sion. The necessity of rectal, vesical, and vaginal examination should never be forgotten. In addition, it is neces- sary to have a good working knowledge of all that chemical and micro- scopic analysis will reveal. Lastly, inflation of the stomach and colon will throw much light on the diagnosis. Under certain conditions examination of the abdominal cavity is rendered very difficult. These conditions are: I. Rigidity of the abdominal wall. This is especially the case in Fig. 178. — Most Frequent Locations or Xarious Tumors of THE Abdominal Viscera. The black arrows indicate the directions in which they grow: L, Liver; G, gallbladder; Py, pylorus; Pa, pancreas; R, right kidney; LK, left kidney; Sp, spleen; IC, ileocecal tumors; V, tumors due to distended bladder, ovarian cysts growing upward, fibroids of uterus, ABDOMINAL TUMORS. 287 infants and young children, in nullipara;, in muscular male adults, or where inflammatory changes are present. It may be necessary to give an anesthetic to overcome this resistance. 2. A great amount of fat in the abdominal wall. This is one of the greatest obstacles, and is not always overcome, even though the abdomen be relaxed or an anesthetic be given. 3. The presence of free fluid in the peritoneal cavity. Fig. 179. — Method of Palpating the Gallbladder or Pylorus. The patient should be laid upon the back with the shoulders slightly raised and thighs flexed upon the abdomen, so that the soles of the feet rest squarely upon the bed. The examiner should approach the patient from the right, laying the hand flat upon the abdomen, and insert it gradually deeper while the patient is in- structed to breathe, and thus relax the abdominal wall. In such cases it is often necessary to tap the abdomen and exam- ine the patient before the fluid has had an opportunity to reaccumulate. 4. The presence of a considerable degree of tympanites. 5. The presence of a distended bladder. In general, the best posture for examination is with the patient lying upon the back, with the shoulders raised and thighs flexed upon the abdomen. Certain special postures and methods are described with the form of tumor in which they arc of use. I. Ins peel ion. — This shows us the following: (a) The dilatation of the superficial veins. This may indicate 255 THE ABDOMEN. obstruction in the portal circulation if central, and in the vena cava inferior if lateral (Fig. i88). (b) The color of the skin. A change involving the color of the entire body, for example, jaundice in carcinoma of the pancreas (Fig. 1 86) or anemia in malignant conditions, may occur. (c) Where the enlargement, if visible, is located, i. e., ascites causes a general widening, while ovarian cysts enlarge the lower portion of the abdomen. Tumors of the spleen or kidneys enlarge their corresponding lateral regions. A dilated stomach or a pancreatic cyst causes a prominence around the umbihcus. Fig. i8o. — Areas of Dullness and Tympany Respectively m Ascites and Ovarl^n Cyst. II. Palpation. — The warm hands should be laid flat upon the abdomen (Fig. 179), deeper pressure being made gradually. For renal tumors bimanual palpation is necessary (Fig. 160). Ballotte- ment is useful for deep tumors. Palpation reveals: (a) The respiratory mobility of the tumor. Tumors of the stomach, liver, and gallbladder and kidneys move up and dowm with respiration unless they are fixed by adhesions. Tumors of the ovary and uterus do not move with respiration. (b) The passive mobihty . of the tumor. Tumors of the large intestine and mesentery and long pedunculated ovarian and uterine TUMORS OF THE STOMACH. 289 tumors have an almost unlimited range of mobility. The same is true for a movable spleen, but is rarely so for a tumor of the pylorus, kidney, or suprarenals. Retroperitoneal tumors arising from the pancras and glands have but little passive mobihty. This also holds for inflammatory tumors like encapsulated exudates (Fig. 192). (c) The presence or absence of fluctuation. {d) The consistency, size, and nature of the surface and edges of the tumor, and whether there is pulsation, genuine or transmitted. III. Percussion. — This will aid in distinguishing ascites from an ovarian cyst, the former causing dullness in the flanks and tympany in the center, and the latter the opposite (Fig. 180). Percussion will also help in distinguishing tumors with fluid or sohd contents, and lying close to the abdominal wall, from those behind coils of intestine or the stomach. IV. Auscultation. — This is of httle value except in the differentiation of a pregnant uterus from other abdominal tumors or in the diagnosis of aneun^sm. Inflation of Stomach or Colon. — This is of great aid in the diagnosis of tumors of the stomach, large intestine, and of retroperitoneal tumors (kidney, pancreas, adrenals, lymph-nodes, etc.). The results obtained from this method of diagnosis are described below. TUMORS OF THE STOMACH. These are almost always due to a carcinoma, rarely to a sarcoma.^ The only forms of cancer of the stomach which can be felt through the abdominal wall are those which are situated at the pylorus alone or which involve the entire anterior wall as a massive infiltration. Tumors of the stomach, especially those of the pylorus, show dis- tinct respiratory, and a marked range of passive mobihty (Fig. 181) If the stomach is at a lower level, as the result of a gastroptosis or of a dilatation, there is but little respiratory mobility in the tumor. The same is true if adhesions exist. Minkowski has shown that if one grasps a gastric tumor during inspiration and holds it, the expiratory upward movement can be prevented. Pyloric tumors move to the right and downward when the stomach is inflated, those of the anterior wall move downward, and both varieties become less accessible to palpation when the stomach is inflated. ^ The subject of diagnosis of gastric carcinoma is taken up in detail on page 335. 19 290 THE ABDOMEN. Tumors of the stomach are most frequently felt in the epigastric and umbilical regions, but may be situated at a lower level if a gastrop- tosis or dilatation (Fig. 181) is present. This can be elicited by inflation. One can often cause peristaltic waves to pass across the stomach toward the tumor, if dilatation exists, by gently tapping upon the organ. Gastric tumors are usually hard and smooth, but may be quite nod- ular. They are tender on palpation. The diagnosis of whether such a tumor is a gastric carcinoma can be made if the accompanying symp- toms referred to on page 335 are present, and by excluding the following forms of tumors. Differential Diagnosis. — i. Pan- creatic Growths. — The normal pancreas in elderly persons with thin, relaxed abdom- inal walls often feels like a gastric cancer. Neoplasms of the head of the pancreas may also simulate car- cinoma of the stom- ach. If the stomach and colon are both inflated, the pancreatic enlargements disappear (Fig. 182). In pancreatic disease there is often an accompanying glycosuria, and stools containing free fat and undigested meat particles (see page 299). There may also be ascites, icterus, and hepatic enlargement (Figs. 186 and 187). 2. Tumors of the Transverse Colon and Duodenum. — Those of the former, cause obstruction symptoms. They disappear when the stomach is inflated, and become more prominent when the colon is inflated. In Fig. 181. — Mobility of Pyloric Tumoks. The dotted circles of the upper figure represent the range of mobih'ty of some pyloric tumors resulting from carcinoma of the stom- ach. The black arrow shows the direction of peristaltic waves. G, Location of stomach and of pyloric tumors in latter right iliac region, in cases of gastroptosis, or of extreme dilatation of the stomach. TUMORS OF THE LIVER. 291 addition, there is an absence of pathologic change in the gastric contents analysis. Tumors of the duodenum cannot be distinguished from those of the stomach, but while hydrochloric acid is absent in the vomitus of the latter, it is usually present in the vomitus of tumors of the duodenum. 3. Carcinoma of the Gallbladder. — Icterus is usually present. There is no lateral mobility and no respiratory fixation as described above. There are rarely any dyspeptic disturb- ances or signs of a dilated stomach. A history of previous gallstone attacks is usual. 4. Tumors 0} the Left Lobe of the I^iver. — These become very prominent beneath the abdominal wall when the stomach is inflated (see page 297). 5. P erigastritic Thickening Around an Old Ulcer of the Stom- ach. — The induration may be so marked as to simulate a carcin- oma. The course of the case is much slower, there is a his- tory of ulcer, and the stomach contents will show hyperchlorhydria. compared with carcinoma, which is most frequent in the aged. Fig. 182. — Location of Pancreatic Cysts Before and After Inflation of Colon and Stomach. V, Stomach before inflation; TC, location of transverse colon before inflation. The black oval area represents the pancreatic tumor, which may be quite prominent before inflation of the stomach and colon, but disappears when the latter procedure is used. The white dotted lines, IV and IC, represent the locations of the inflated stomach and colon respectively, overlapping the pancreatic tumor. It usually occurs in younger individuals, as TUMORS OF THE LIVER. I. Corset Liver. Through the pressure of a corset, a lobule of the liver may become almost completely separated from the remainder of the organ and simulate other tumors of the upper abdomen. It occurs most frequently 292 THE ABDOMEN. in the right lobe. A deep groove or furrow divides the hver proper from the supemumerar}^ lobe which contains, instead of liver tissue, only blood-vessels and bile-ducts. The majority of these tumors cause no symptoms, but they become so far separated as to seem hke a neoplasm having no connection with the liver. It may drag the gallbladder with it, just as does an elongated Riedei lobe (Fig. 162). As a result of this, the gallbladder may be found at the level of the umbilicus or even lower. If the tumor is freely movable, or if the bridge con- necting it with the liver is very thin, there may be great difficulty in diag- nosis. The same is true for those cases in which a coil of intestine lies between it and the liver. The diagnosis, in those cases in which the groove between the acces- sory lobe and the liver is not deep, is easy, if one can feel this transverse de- pression and observe that the tumor moves with the liver during respiration. Differential Diagnosis. — Floating Kidney. — This can be better felt from the lumbar region, while the corset lobe is most distinct an- teriorly. If the colon is inflated, it Hes in front of the kidney (Fig. 191). A movable kidney can be replaced upward and backward toward its noi-mal position, and, on the other hand, can be pushed further Fig. 183.— Front View op a Case of General Enteroptosis (R. C. Coffey). L, Liver outline on surface, sho-n-ing marked descent; S, stomach; note the fact that the lesser curvature lies at the level of the umbilicus, and the greater curvature midway between the umbilicus and symphysis; K, right and left kidneys, showing marked do\vnward displacement; T, transverse colon, also markedly prolapsed. TUMORS OF THE LIVER. 293 dovm than the corset liver. If the patient is laid upon the left side, one can separate the sharp lower edge of the liver from that of the kidney, which is more rounded or blunt. If enteroptosis exists, the diagnosis may become very difficult, since movable kidney may be present at the same time. Renal Tumors. — These often have the shape of the normal kidney and he behind the inflated colon. The dullness over the renal tumor is not continuous with that of the hver, as in a corset lobe, ^ '' v'^l/"'>o but tympany due to the over- lying intestines exists. The lower edge of the renal tumor is not as sharp and lacks the notches often present in a corset lobe. II. Floating Liver (Hepat- OPTOSIS). A liver which has de- scended in the abdominal cavity may simulate a tumor of the right side. It may sink to the pelvis. It can usually be replaced into its normal position. On palpation, one can usually distinguish the sharp lower edge and the notch between the right and left lobes (Fig. 183). It is ten times as frequent in women as in men, especially in those with flabby, relaxed abdom- inal walls. The consistency of the tumor is that of the normal liver. The normal hver dullness is replaced by tympany, but reappears when the organ is put into its normal position. It may cause at times attacks of pain like biliary colic, radiating to the right shoulder. -Usually it causes a feeling of fullness in the abdomen and digestive dis- turbances. The diagnosis may be very difficult if ascites coexists. It would be necessary to perform paracentesis first. Differential Diagnosis. — Floating or Movable Kidney. — The hepa- FiG. 184. — Sagittal Section in Median Line of a Case OF General Enteroptosis (R. C. Cofifey). D, Under surface of diaphragm; the blank space be- tween D and L (liver) is the space formerly occupied by the liver before its descent; S, prolapsed stomach; T, prolapsed transverse colon; I, prolapsed coil of ileum; note elongation of the mesentery as the result of the prolapse. 294 THE ABDOMEN. tic tumor is larger, more superficial, has the characteristic sharp lower edge, is notched, and there is an absence of normal hver dullness until the tumor is replaced. The renal tumor has the outline of the normal kidney and lies behind the colon, when this is inflated (Fig. 191). Tumors of the Liver Itself. — In carcinoma the surface is irregular and often umbilicated, and the liver, if enlarged much downward, also extends upward to its normal level at the sixth rib. The same is true for hydatid cysts. Tumors and Cysts of the Omentum. — These, though movable, cannot be replaced to the same extent from above do\\mward as a floating Hver, and are separated by tympany (intestines) from the dullness of the normally placed liver. III. EcHiNococcus Cysts of the Liver. This condition usually occurs in a unilocular form and is most often in the right lobe, causing a localized bulging on the surface and giving rise to a marked tumor. The liver is enlarged, and if the cyst is near the upper surface, it pushes the diaphragm upward. The normal liver dullness is increased upward in a circumscribed manner, as in a pleural effusion, but differs from it by having respiratory movement. When the cyst lies near the lower border of the right lobe it causes a tumor, resembling a distended gallbladder or renal enlargement. When the cyst protrudes from the anterior surface of either the right or left lobe, it causes a marked locahzed bulging. These latter forms rarely give a sense of fluctuation, and the pecuhar hydatid thrill, so pathognomonic when found, is an inconstant sign. The presence of echinococcus can be suspected from the presence of a locahzed tumor with absence of constitutional signs, such as fever, unless, as rarely occurs, suppuration has taken place. The diagnosis can be positively made only if the characteristic scohces or booklets are found in the clear, watery contents. Explor- atory puncture is dangerous and should be replaced by a laparotomy for diagnostic purposes. An .T-ray is of great aid in confirming a diag- nosis of echinococcus if calcification has occurred. Differential Diagnosis. — i. Echinococcus cysts of the anterior surface must be differentiated from the following: (a) Cystic Disease of the Liver. — The elevations are usually small and multiple. If large, they can be differentiated from echinococcus cysts by exploration only. TUMORS OF THE LIVER. 295 (b) Carcinoma. — Here there is cachexia, umbihcation of the tumors (Fig. 185), and the tumors are harder and muhiple. (c) Abscess of the Liver. — If no fever is present the differentiation may be very difficuh, but in abscess the tumor is not so hard or tense. Usually, however, fever and other septic symptoms are present in hepa- tic abscess, and there is a history of dysentery to be obtained. If a hy- datid cyst suppurates the diagnosis from primary liver abscess is almost impossible before operation. 2. When the hydatid cyst projects from the lower border. (a) From a Dilated Gallbladder. — This tumor of the gallbladder is pear-shaped, it can only be separated from the edge of the liver with difficulty and is also more movable than an echinococcus cyst. (b) Permanent or Intermittent Hydronephrosis. — In the intermittent form there is a history of alternating disappearance and presence of the tumor, the former associated with polyuria. A permanent hydronephrosis will have more or less the form of the normal kidney, project more in the lumbar region, and lie behind the inflated colon (Fig. 191). If the patient is laid upon the left side the echinococcus cyst is less prominent. 3. When the echinococcus cyst is on the upper border of the liver. {a) From Pleuritic Effusion. — The diagnosis can only be made by finding the booklets in the fluid removed by exploratory puncture. An upper border of dullness, not unlike that found in subphrenic abscess, occurs in the case of an echinococcus cyst of the upper surface of the liver; i. g., the upper border is convex upward either in front or behind (Fig. 163), while in pleural effusion it is almost horizontal (Fig. 140). (Jb) From Hydatids of the Lung and Pleura. — A differentiation is almost impossible if situated on the right side. Hemoptysis and cough are more frequent in hydatids of the lung. (c) From Subphrenic Abscess. — Here the history of a primary cause of suppuration, e. g., in the appendix, and the presence of fever, etc., are of aid. If the abscess contains gas there is tympany instead of dullness, and the .v-ray will not show a shadow, as in hydatid. Ex- ploration will reveal the absence of booklets and the presence of pus. IV. Cystic Disease of the Liver. This condition, resembling congenital cystic disease of the kidneys (Fig. 192), is often present with the latter condition, and should be suspected if the liver and both kidneys are enlarged in a patient having uremic symptoms. The surface of the liver is nodular and some of the many cysts may be large enough to simulate hydatids. In such a 296 THE ABDOMEN. case a differentiation is impossible without a microscopic examination of the wall of the cyst and its contents. V. Syphilis of the Liver. There are three forms of syphilis which are of interest from a sur- gical standpoint. 1. Cases of large gummata resembling neoplasms. 2. Cases of division of the right or left lobes or both into multiple lobules as the result of cicatrization following gummatous infiltration. 3. Cases with irregular fever and gumma formation resembling hepatic suppuration. 4. Cases resembling gallstones. The first point in the case of gummatous enlargements is to identify the tumor as belonging to the liver, then to ascertain the presence of syphilis elsewhere or a previous history of the disease, and finally to observe the disappearance of the tumor under antisyphilitic treatment. If a gumma softens and fever is present, one cannot differentiate it from a hepatic abscess, in the absence of a syphilitic history. The. chief condition from which a lobulated luetic liver must be distinguished is floating kidney. The latter has a much greater range of mobility, has the form of the normal kidney, and can be best felt by bimanual palpation (Fig. 160). Inflation of the colon shows the tumor to lie behind the distended large intestine. Rarely obstructive jaundice, with attacks of bihary colic, may follow the pressure of a gumma, or the traction of syphilitic cicatrices on the portal fissure (Rolleston, Bilhngs). VI. Malignant Neoplasms of the Liver. Sarcoma and carcinoma both occur as primary and secondary growths in the liver. The primary are quite rare and cannot be distin- guished clinically from the secondary forms. The stomach (Fig. 204), colon, gallbladder, and breast (Fig. 152) are the most frequent seats of the primary growths, in cases having secondary cancer of the Hver. Sarcomata are most often secondary to primary melanosarcomata of the uveal tract and of the skin. The diagnosis of malignant disease may be made from the onset of cachexia, the rapid enlargement of the liver, and the palpal^le, hard, umbilicated tumors (Fig. 185) of the li\-cr edge. In a patient who has a primary growth elsewhere, the diagnosis is positive; but in one in whom no such focus can be found, the diagnosis is a very probable one. At times, especially in the case of primary sarcomata, one lobe may Fig. 185. — Metastatic Carcinoma of the Liver Secondary to the Primary Carci- noma OF THE Stomach Shown in Fig. 204. Note the umbilicated centers of each nodule. This illustration assists in forming a conception of the innumerable metastases from a comparatively insignificant primary carcinoma. TUMORS OF THE GALLBLADDER. 297 be enormously enlarged and its surface smooth and firm. From their location, such tumors can be diagnosed as being hepatic in origin, and inflation of the stomach will render them more prominent. In addition to the above symptoms, there are marked jaundice (even cholemia with hemorrhages into the skin and from the mucous mem- branes), ascites, evidences of metastases in the peritoneum, and often febrile manifestations. Differential Diagnosis. — i. Cirrhosis of the Liver. — The nodula- tion of the surface is never as marked and umbilicated as in carcinoma. If ascites is present, as is the case in both affections, the fluid should be removed before palpating the liver. The jaundice is not as deep in cirrhosis. Rapid enlargement of the liver and marked cachexia speak for malignancy. A search for a primary focus of cancer or sarcoma should always be made. The spleen is usually enlarged in cirrhosis, but is rarely so in malignant disease. 2. Syphilis. — Gummata are usually not as hard as carcinomatous nodules, there is a history of syphilis, and the constitutional disturbance is shght. The course is much more chronic. TUMORS OF THE GALLBLADDER. The two chief affections which might be mistaken for other abdom- inal tumors are hydrops and primary malignant disease of the gall- bladder. Hydrops. — Distention of the gallbladder occurs as the result of blocking of the cystic duct, followed by the accumulation of secretions, and the formation of a tumor which varies greatly in size. It may be quite movable or fixed by adhesions. There are three degrees of dis- tention: (a) Those in which the tumor is of relatively small size. (b) Cystic tumors of great size extending to the left of the median line. (c) Cystic tumors filling the greater part of the right side of the abdomen (Fig. 162). The diagnosis in the lirst class may be made from the fact that there are but few subjective symptoms, although a history of one or more attacks of bihary coHc is often obtainable. Its outline can often be seen through a thin abdominal wall. It can be felt to be attached to the liver above, is in close contact with the anterior abdominal wall, and has a wide range of mobility. Palpation and percussion are often very unsatisfactory, for the 298 THE ABDOMEN. reasons that unless adherent the tumor is so movable that it cannot be readily grasped, and, again, instead of dullness there is tympany from the underlying intestines. If the abdominal wall is quite relaxed, its lower rounded border may be distinctly felt as a tense elastic body, especially if one hand be placed posteriorly and the other in front, as in palpating the kidney (Fig. 160}. Inflation of the stomach makes the tumor more prominent and pushes it to the right, while inflation of the colon pushes it upward, un- less, as rarely occurs, the colon is adherent between the tumor and the abdominal wall. Exploratory puncture is dangerous. The larger forms of cystic tumors of the gallbladder which fill the greater part of the right half of the abdomen are infrequent, and can be recognized from the history, from their great mobility, smooth sur- face, their pyriform or cucumber shape (i\.lban-Doran), and the fact that they have their pedicle at the liver, instead of in the pehis as ovarian cysts do. If adhesions exist there may be great difficulty in diagnosis. There is often distinct fluctuation in these large gall- bladder retention-cysts. Differential Diagnosis. — i. Floating Kidney. — This always re- tains the characteristic outhne of the kidney. It can be replaced toward the renal region. Inflation of the colon causes it to disappear while the gallbladder tumor is pushed upward. 2. Groiiihs in the Stomach and Intestines. — These can be distin- guished by the difference in the symptoms and by the results of inflation of the colon and stomach. 3. Echinococcus Cysts or Malignant Tumors Projecting from the Lower Edge of the Liver. — These are much more irregular in outhne, harder, and not movable except with respiration. 4. Distention of the Gallbladder Following Cancers of the Pancreas. — In this, it may distend to a quite marked size, but there are an accom- panying cachexia, ascites, and deep jaundice (Fig. 186). Explora- tory incision shows the head of the pancreas infiltrated and enlarged. Malignant Disease of the Gallbladder. This frequently follows cholelithiasis, and should be suspected if a hard mass is found in the right hypochondriac region following a history of gallstones in an elderly patient with persistent jaundice. The tumor is usually nodulated, rarely smooth, and is very hard in consis- tency. This induration, the nodular surface, and the rapid appearance of cachexia followed by icterus and ascites, serve to distinguish it from PANCREATIC TUMORS. 299 cholelithiasis; but in the latter the organ may be indurated so that a diagnosis is often not made until the abdomen is opened. The pains in cancer are not sharp and colicky, but of a dull character. If fever and colicky pains appear, they indicate an infection of the carcinoma- tous gallbladder. The course is a very chronic one. PANCREATIC TUMORS. Inflammatory tumors in the epigastric and umbihcal regions due to peripancreatic suppuration following an attack of acute pancreatitis were referred to on page 270. Other tumors due to pancreatic disease may be divided into three classes. (a) Those due to chronic pancreatitis. (b) Cysts. (c) Neoplasms. Chronic Pancreatitis. Although the majority of these cases can be recognized only at opera- tion or autopsy, it is important to know that marked induration can follow chronic pancreatitis. At times it is possible to recognize the tumor through the intact abdominal wall during life, and in one case of the author's such a tumor was mistaken for a carcinoma of the head of the pancreas. The diagnosis of chronic pancreatitis can rarely be made. Even when the abdominal cavity is opened, as in the case just mentioned, the induration is difficult to distinguish from that of carcinoma, and the diagnosis can only be made from the sub- sequent clinical course. The tumor is palpable and is located in the epigastrium to the right of the middle line. In the cases observed by Riedel and in my own case the tumor had so great a range of respi- ratory and passive mobihty as to be mistaken for a gallbladder full of calculi. If, in addition to such a rarely palpable induration, jaundice, fatty stool, glycosuria, and emaciation are present, chronic pancreatitis can be diagnosed. There is often a history of bihary colic, of gastro- duodenal catarrh, or of gastric duodenal ulcer. Differential Diagnosis. — i. GaUslones in the Common Duct. — In this condition there is the history of frequent attacks of biliary colic at first without jaundice, chills and fever, but later accompanied by these symptoms. The absence of tumors speaks also for gall- stones in the common duct. 2. Cancer of Head of Pancreas. — The jaundice is deep and constant. 300 THE ABDOMEN. the liver and gallbladder are greatly enlarged, and ascites is present. Emaciation is also more rapid. In some cases only exploratory incision will aid in making a diagnosis. As mentioned above, palpation of the tumor will, at times, give misleading information, since the induration in choronic pancreatitis may be as great as in carcinoma. More Fig. iS6. — Front View of Case of Carcinoma of the Head of the Pancreas. The area of liver dullness is outlined in black. R, Right lobe of liver; L, left lobe of Kver. The notch between the two lobes could be distinctly palpated to the left of the median Hne at the level of the umbihcus. G, Enormously distended gallbladder easily palpable through the abdominal wall. Enormous size of the liver was due to passive hyperemia and to secondary deposits in the liver parenchyma. The yellowish color of the skin was due to pressure on the common duct. rehance is to be placed on the presence of deep icterus and ascites, which speak for mahgnancy. 7,. Gallstones in the Gallbladder. — There is tenderness over the gallbladder, (Figs. 167 and 173) and the history of attacks of biliary coHc. The tumor is seldom as hard as that of a chronic indurative pancreatitis and does not disappear when the stomach and colon are inflated, as the pancreatic induration does. PANCREATIC TUMORS. 301 Pancreatic Cysts. These cause a bulging in the median hne of the epigastric region (Fig. 182) or between the middle hne and left costal arch. In sixteen cases Koerte found the tumor below the navel, and in eleven cases Koerte and Neumann/ his assistant, have observed right-sided pan- creatic cysts lying near the kidney (Fig. 191) and simulating renal tumors. There is an area of dullness over the tumor. The epigastric bulging is smooth, tense and rounded, and may vary in size from time to time. Fig. 187. — Side View of Case of Carcinoma of the Head of the Pancreas. Yellow tint of flesh due to obstruction of common duct, as it passes through head of pancreas to reach the duodenum. G, Enormously distended gallbladder which could be distinctly felt through the abdominal wall. Its contents were cystic on account of the long-standing obstruction of the common duct. R, Lower border of right lobe of liver, which is enormously enlarged oa account of secondary deposits. The upper level of liver dullness is shown just below the level of the nipple. A, Area of dullness due to free fluid in peritoneal cavity due to pressure upon portal vein. Such tumors have no respiratory or passive mobihty, and inflation of the stomach and colon causes them to disappear, the former lying above and the latter below it (Fig. 182), unless one of the following rare positions of the cyst occurs: (a) The cyst lies above the stomach and pushes the latter downward. (b) It may be behind the transverse colon. (c) It may lie below the transverse colon. (d) It may lie behind the ascending colon (Fig. 191). In these positions the cyst is often quite mobile. ' "Deutsche Zeitschrift f. Chirurs Bd. l.x.xiv. 302 THE ABDOMEN. The diagnosis may be made from the above special characteristics of the tumor, from the mode of onset, the accompanying symptoms, and the analysis of its contents when obtained at operation. The modes of onset are chiefiy three: 1. Gradual. — With loss of weight, symptoms of indigestion, and cohcky pains like those of gallstones. 2. Sudden. — After blows on the upper abdomen. 3. No preceding trauma or symptoms mentioned under i. After the cyst begins to develop the patient may either have severe pain and vomiting or show no symptoms other than the gradually increasing distention of the abdomen. Jaundice, hematemesis, and diarrhea are occasionally present. In the urine sugar is often found; in the feces, an excess of fat and undigested meat may be found. The fluid should never be obtained for analysis by exploratory puncture, but only during a laparotomy. The most important diagnostic feature is that the fluid in a pancreatic cyst digests fibrin and albumin. Differential Diagnosis. — Echinococcus Cysts of the Liver. — The tumor in these is continuous with the hepatic dullness, while in pancreatic cysts there is an area of resonance between the tumor and the liver, which is increased when the stomach is inflated. When the pancre- atic cyst lies above the stomach these signs are of no value, but this form_ of pancreatic cyst is much more movable than is an echinococcus cyst. Retention-cysts of the Gallbladder. — -These were discussed on page 297. The chief points are their greater mobility and the continuation of dullness from the liver to the tumor. Renal Cystic Tumors. — If, as shown in Fig. 191, the tumor lies behind the colon, a differentiation is impossible, and even after opera- tion the fluid may fail to show any characteristic ferments in such cases. In general, however, renal tumors are accompanied by colicky pains along the ureter, by urinary changes, and give rise to more bulging of the ileo- costal space. In the most frequent location of pancreatic cysts (Fig. 182) the colon when inflated lies below the tumor and not in front of it. Ovarian Cysts. — When these have a long pedicle they may simu- late a pancreatic cyst. The presence of both ovaries in the pelvis will exclude ovarian tumor. Bimanual pelvic examination in the Trendelenburg position will show that the tumor has no relation to the ovaries. The history will show that the tumor first appeared in the epigastrium. Upon inflation of the colon, the ovarian lies below and the pancreatic cyst above it, except in those rare cases where these latter he below the colon. PANCREATIC TUMORS. 303 Mesenteric Cysts.— The history is of great value. Appearance of the tumor after an injury or following colicky pains speaks for a pan- creatic cyst, as do fatty stools, glycosuria, undigested meat fibers in the feces, and emaciation. The mesenteric cyst is more movable, lies below the umbilicus, and when the large bowel is inflated the transverse colon lies across the tumor. Only when a pancreatic cyst has developed between the layers of the transverse mesocolon is differentiation im- possible. Neoplasms of the Pancreas. Primary carcinoma of the head of the pancreas is the most frequent form of new-growth. The diagnosis may be made from the follow- ing symptoms : 1. Severe pain in the epigastrium, radiating through to the back. It is either continuous (a dull ache) or intermittent (agonizing). 2. Jaundice. This is present except in cancer of the body or tail. 3. Distention of the gallbladder and enlargement of the Hver (Fig. 186). 4. Ascites. 5. Early cachexia. 6. A palpable tumor in the epigastrium which becomes less notice- able when the stomach is inflated. 7. Free fat and undigested meat fibers in large quantities in the feces. 8. Albuminuria — rarely glycosuria. Differential Diagnosis. — i. Gallstones in the Common Duct. — The jaundice is more sudden in its appearance and often accompanied by irregular chills and fever. There is often a history of frequent previous attacks of biliary coHc without jaundice and the gallbladder itself is tender to the touch. On inflating the stomach and colon the tumor will not' disappear, as pancreatic tumors do. Ascites and cachexia speak for malignant disease of the pancreas. 2. Chronic Pancreatitis. — In the absence of ascites and jaundice, it is impossible to differentiate this from carcinoma "except by the fact that in the latter there is early and much more marked cachexia. The induration in chronic pancreatitis often feels as hard at operation as in cancer of the head of the pancreas. In the latter, however, the con- dition becomes progressively worse, while in chronic pancreatitis it -improves as soon as stones in the common duct arc removed. 3. Carcinoma 0} the Pylorus. — The tumor is much more mobile than in cancer of the pancreas, there is a predominance of gastric symptoms with evidences of dilatation, and changes in the gastric 304 THE ABDOMEN. juice. A cancer of the pylorus will not be accompanied by jaundice, ascites, and changes in the stool, and the tumor will move to the right when the stomach is inflated instead of becoming concealed, as does one of the pancreas. 4. Carcinoma of the Colon. — This may be accompanied by ascites, but there are no changes in the stools, or jaundice, as in cancer of the pancreas. The tumor is more movable than that of the pancreas and does not disappear when the colon is in- flated. There are of- ten distinct stenosis symptoms. TUMORS OF THE SPLEEN. The normal spleen cannot be palpated except in very thin and relaxed patients and then only indistinctly. The conditions which most often give rise to splenic tumors are: 1. Floating spleen. 2. Splenic enlarge- ments due to leukemia, pseudoleukemia, ma- laria, or acute splen- itis. 3. Neoplasms, in- cluding echinococcus cysts. Floating or Wandering Spleen. — This condition is frequently present as a part of a general enteroptosis (Fig. 183), or is often asso- ciated with left-sided floating kidney. A tumor may be found which has caused practically no symptoms except a slight dragging sensation. Quite rarely the tumor may give rise to acute symptoms, such as pain, vomiting, muscular rigidity, and tenderness, due to strangulation or twisting of its pedicle. A wandering spleen is most often found in the left iliac region, Fig. 1S8. — Enlargement of Abdomen as the Result of a Leu- kemic Hypertrophy of the Spleen. The dark color of the skin of the abdomen is due to the repeated ap- pUcation of the .r-ray. TUMORS OF THE SPLEEN. 305 resting in the iliac fossa. Less often lias it been found in the right iliac fossa and pelvis. In the latter situation it may cause obstruc- tion. A diagnosis is made by the palpation of the characteristic notches (Fig. 189) along' its anterior border, its smooth surface, and the absence of the spleen in its normal place. It can be distinguished from floating kidney by the fact that the latter can be replaced to the renal while the spleen disappears behind the costal arch unless held by adhesion. A floating kidney lies be- hind the colon, has the outhne and rounded lower pole of the normal kidney, and in addition is much less movable than a floating spleen. Enlargements of the Spleen. — These are described at length in text-books of medicine. The writer has seen a number of cases in which such spleens, enlarged as the result of general dis- eases, such as leukemia (Fig. 188), pernicious anemia, pseudoleuke- mia, chronic malaria, and syphiHs, have been mis- taken for neoplasms of the spleen. In every case of splenic enlargement of long standing one must remember the above causes and examine the blood or search for a cause elsewhere than in the spleen. Another cause of enlarged spleen is that found in si)lcnomcgaly or Banti's disease, which may or may not be associated with anemia. For full descriptions of the various forms of this disease the reader is referred to the various treatises on internal medicine. Fig. 189. — Anterior View of the Case of SARroiiA of the Spleen Shown in Fig. 190. The outlines of the spleen have been marked with a dotted line. Observe the notches on the right margin of the tumor, characteristic of splenic tumors. E, Ensiform process in costal arch. Observe the formation of a well-marked caput medusae. 3o6 THE ABDOilEX. There are certain physical signs by which all of these enlargements may be recognized as splenic, viz. : 1 . They retain the general outhne of the spleen. 2. They have its notched anterior border. 3. They he in front of the inflated colon and not behind it, as do renal tumors. 4. They have respiratory mobility. (a) Echinococcus of the Spleen. — This is very rare and causes an enlargement of the spleen which can seldom be diagnosed before opera- r w ^" V / ' i 1 / ' ^^^ ' / ; ^^P / / ""x \L / / ;' ,; ■j jk '\^ c/ /u . .-rcvi p 1 6. * ' Fig. 190. — Lateral View or Abdoiten of Same Patiext as Sho\^"nin Fig. 1S9, with S.\rcoma of the Spleen. L, Lower palpable border of tumor; U, upper border of tumor as outlined by percussion; C, costal arch. tion. Occasionally fluctuation may be felt and the tumor recognized as one of the spleen. Sarcoma of the Spleen. — Both primary sarcoma and carcinoma of the spleen occur, but of the two, the former is the more frequent. The tumor occupies the left half of the abdomen, extending do\^Tlward from beneath the left costal arch (Fig. 189). It lies quite superficially, has a nodulated, hard surface, and often retains the characteristic notches of the anterior border of the spleen (Fig. 189). Its rapidity of growth, its hardness, and the accompanying cachexia are diagnostic of the malignant character of the tumor. It lies in front of the inflated colon and does not give rise to hematuria, as does a mahgnant renal tumor. It also causes early peritoneal metastases which can be felt as separate tumors. TUMORS OF THE INTESTINES. 307 TUMORS OF THE INTESTINES. There are three places in the abdominal cavity where tumors which have their origin in the small and large intestine may be felt. These are, in the order of their frequency: 1. Rectum. 2. Sigmoid flexure. 3. Cecum and ascending colon. The rarer seats of a tumor are the appendix, duodenum, ileum, and jejunum. Unfortunately for the purposes of diagnosis, a palpable tumor is a rather late sign of malignant disease of the intestine, so that it should be made from the other signs and methods referred to on page 308. Those of the rectum are discussed on page 359. At this point the diag- nostic points of intestinal tumors -per se will be discussed whether due to neoplasms or inflammator}- conditions. I. Inflammatory Tumors. — These are the result of one of two affections, viz. : tuberculosis and actinomycosis. They are almost always found in the cecum. Quite rarely tumor-like inflammatory masses appear around the sigmoid as the result of perforation of the appendices epiploic^. (a) Ileocecal Tuberculosis. — In this a vertical, sausage-shaped, hard tumor is found in the right iliac region w^hose tuberculous nature is often not suspected. The diagnosis frequently made before operation is that of a carcinoma. The tumor is quite fixed and more sensitive to pressure than a carcinoma, and is not quite as hard. There are also periodic attacks of severe pains, as the result of an enterostenosis, and alternating diarrhea and constipation is a quite common symptom. Rarely symptoms of acute intestinal obstruction arise. The disease occurs, as a rule, at an earlier age than carcinoma; there is often fever and it is not accompanied by as much emaciation as is the malignant process. The finding of blood in small quantities is more characteristic of carcinoma than of tuberculosis. (b) Ileocecal Actinomycosis .-—This localization of the ray-fungus gives rise to a tumor-like mass greatly resembling that of ileocecal tuberculosis. The mass is, however, more commonly attached to the abdominal wall, which is indurated. In the absence of a history of a focus of actinomycosis elsewhere it is impossible to make a diagnosis until sinuses have formed, in the pus of which the characteristic ray- fungus is found. The tumor is as fixed, but not as tender as in tuber- culosis. It is not as hard nor does the general nutrition suft'er as much 306 THE ABDOMEN. as in carcinoma. The latter usually appears at a more advanced age (above forty), although there are exceptions to this. The condition is usually accompanied by some fever. The administration of potassium iodid or of copper sulphate, as recently recommended by Bevan,^ may aid in making a differential diagnosis, since these cause an improvement if the tumor is the result of an actinomycotic infection. 2. Neoplasms of the Intestines. — Benign tumors are relatively rare and can seldom be diagnosed before operation. They give rise, if large, to symptoms of chronic stenosis and may cause intussusception. Of the mahgnaht growths, sarcoma occurs in about 6 per cent, of the cases, the remainder being due to carcinoma. The most frequent locations, according to recent statistics of Tuttle,^ in 2432 cases, exclusive of the stomach, are as follows: Rectum 1690 cases. CecTim and ascending colon 283 Sigmoid 182 Transverse and descending colon 160 Appendix 60 Ileum, jejunum, and duodenum 69 The clinical picture varies according to the seat of the growth, but is generally that of a stenosis of the bowel. Cancer of the Duodenum. — The symptoms are so closely alhed to those of a pyloric cancer as to be indistinguishable, even when a tumor is palpable, which is usually not the case until late in the disease. Cancer of the Remaining Small and Large Intestine except Rectum. — The diagnosis of cancer anywhere between the duodenum and rectum is usually to be made from a combination of certain general and local symptoms. The general signs are a gradually increasing anemia and cachexia for which no other cause can be found. These, when asso- ciated with intestinal disturbances in a person above forty, should always lead to the suspicion of a mahgnant growth. On the other hand, there are cases in which the general and local symptoms are so latent that a suspicion of malignancy is not aroused until a tumor which has all the physical characters of an intestinal one, is found during an abdominal or pelvic examination. Quite rarely cases of carcinoma of the intestine have an acute onset accompanied by fever, and a diagnosis is made only at operation, for what was thought to be an acute inflam- matorv condition. The chief local diagnostic points are: I. Symptoms of Stenosis. — These are increased visible peristalsis ^ "Journal American ISIed. Association," Nov. 11, 1905. " "^ledical Record," Xov. 4, 1905. TUMORS OF THE INTESTINES. 309 and severe, griping, colicky pains, often referred to a particular spot and relieved as soon as flatus has been passed per rectum. Often, however, the patient does not pass any gas after these cohcky pains, and this is quite characteristic of stenosis. 2. Condi tioji of the Bowel Movements. — Obstinate constipation is present in the majority of the cases. This condition often alternates with diarrhea, which may be a prominent early symptom, especially when accompanied by the frequent but unsuccessful desire to go to stool. The nearer the cancer is to the rectum, the more marked is this tenesmus. The feces may be ribbondike if the stenosis is low down. The appearance of pus, blood, and mucus in the stools is of great value if a dysentery can be excluded. 3. Tumor. — The chief characteristic of intestinal tumors is their great mobihty. This is especially true of those of the small intestine, sigmoid, and transverse colon, less so of those of the cecum or of the hepatic and splenic flexures. The latter can often be best felt by gradually pushing the hand under the costal arches. The tumors are very hard and nodular. They may appear to be larger at one examination than at another, owing to the fact that. feces collect on the proximal side, from time to time. The hardening of the tumor caused by the contraction of the hypertrophied musculature on the proximal side of the stenosis, followed by a gurgling sound due to passage of gas through the stenosis, may often be felt and heard. Ascites may be an early symptom, accompanying a tumor of the colon. Differential Diagnosis. — -The conditions from which cancer of the small and large intestine must be differentiated depend upon their respective locations. They are as follows : Those of duodenum and transverse colon Cancer of pylorus, of head of the pancreas. Tumors of omentum and mesentery. Those of hepatic flexure Cancer of gallbladder. Tumors of liver. Tumors of right kidney. Those of splenic flexure Tumors of spleen. Tumors of left kidney. Those of cecum and appendix Actinomycosis and tuberculosis of cecum. Post-appendiceal induration. Those of sigmoid flexure Tumors of ovary and uterus. Those of jejunum and ileum Xon-malignant strictures. Those of all parts of colon From fecal impaction and gallstones. 3IO THE ABDOMEN. TUMORS OF THE PERITONEUM AND MESENTERY. Tumors of the Mesentery. — Cystic Tumors. — Cysts constitute the majority of mesenteric tumors; the proportion of soHd to cystic tumors being as i to 4. The smaller cysts have a wide range of passive mobihty and rarely cause any symptoms. The larger ones cause a bulging in the umbihcal region and are not as freely movable. These larger ones push the intestines aside and cause symptoms of stenosis, and in some cases even complete obstruction. They may give the sense of fluctuation. These cysts may be of dermoid, hydatid, serous, bloody, or chylous nature, and are often adherent to the neighboring viscera. Both the smaller and larger varieties of mesenteric tumors may be suspected from the presence of a tumor in the umbilical region, from the fact that they are not adherent to the abdominal wall hke omental tumors, and, lastly, their extreme mobihty, except when very large. They must be differentiated from the following: Tumors of the omentum These are usually adherent to the anterior abdominal wall. Pancreatic cysts. These show some disturbance in the pan- creatic secretion and lie behind the in- flated stomach and colon. Retroperitoneal cysts These are immovable and lie behind the in- flated colon. Ovarian cysts By elevating the pelvis,one can feel the pedicle of these tumors connected with the uterus. Movable kidney and hydronephrosis These retain the outline of the kidney, lie more laterally, and behind the colon. Encapsulated tuberculous peritonitis This may greatly resemble a mesenteric cyst as shown in Figs. 195, 196, but when the patient lies down the enlargement tends to become flatter, while the cysts retain their convex surface. Tumors of the Omentum and Peritoneum. — These, as in the case of the mesentery, are either cystic or solid. Both become adherent quite early to the abdominal wall. Echinoccocus cysts constitute the most frequent variety of cystic tumors, while carcinoma occurs most often in the form of a solid tumor. ' Carcinoma may occur both as a primary and secondary growth. The latter follows cancer of the stomach and intestine. The diagnosis may be readily made if there is a history of a primary growth; but if there is none, it must be made from the presence of certain symptoms. Lipomata are the most frequent form. They do not fluctuate, TUMORS OF THE KIDNEY. 3II although they may yield a sense of pseudo-fluctuation. They grow quite rapidly and cause early stenosis symptoms. If the omentum is chiefly involved, a transverse, very hard tumor is to be felt at or above the umbiHcus. It is adherent to the anterior abdominal wall and accompanied by ascites and progressive emaciation. Multiple hard tumors are to be felt, if the parietal peritoneum is also involved, and these are accompanied by ascites. The transverse tumor may occur both in tuberculous and simple prohferative peritonitis. These, however, occur at a younger age than does carcinoma and emaciation is not nearly as marked. The nature of the fluid in cancer is usually hemorrhagic, but this may also be the case in tuberculous peritonitis. TUMORS OF THE KIDNEY. The best method of examination of tumors of the kidney is by palpation of the abdomen, with the patient in a recumbent position, the knees flexed and shoulders elevated (Fig. i6o), one hand placed over the corresponding renal region, while the other presses the abdom- inal wall in gradually but firmly, using the entire palmar surface of the hand and not the finger-tips alone. Another method which is not as frequently used is that recommended by Israel, which consists in having the patient lie upon the healthy side while the renal region is palpated bimanually on the diseased side. In patients who are not too stout, and whose abdominal walls are relaxed, the lower pole of the kidney may be normally felt a little above the level of the umbihcus at the external border of the rectus abdominahs. Abdominal tumors which are due to abnormal conditions of the kidney may be divided into four classes: 1. Congenital displacements and malformations of the kidney. 2. Movable kidney. 3. Diseases which are accompanied by enlargement of the kidney, such as hydronephrosis, pyonephrosis, pyelonephritis, tuberculosis, nephrolithiasis, and neoplasms. 4. Tumors which are due to neoplasms of the kidney. I. Congenital Displacements and Malformations of the Kidney. (a) It is practically impossible to diagnose a congenital displacement of the kidney before operation. Such kidneys do not give rise to symp- toms unless enlarged through inflammation, and their presence in such abnormal places as the pelvis is seldom suspected. I have seen two 312 THE ABDOMEN. such cases. In one of these the kidney was located over the promontory of the sacrum, and caused some pain, the etiology of which was not clear until the kidney was discovered at operation. In the second case the congenitally displaced kidney was found incarcerated between the pregnant uterus and the rectum and was the cause of the severe dystocia. One may suspect that an abdominal tumor is a congenitally displaced kidney if ureteral catheterization is performed and it is found impossible to catheterize the ureter upon the side of the suspected kidney tumor. Such obstruction may be due to other causes, such as Stricture of the ureter, etc., and the diagnostic value of ureteral catheterization is therefore not great. (b) Congenital malformations of the kidney, such as horseshoe kidney, cannot be diagnosed before operation, unless some change such as a hydronephrosis supervenes, when it may cause a tumor lying transversely at the middle of the pathologically situated kidneys, which can be diminished by compression and which is found to be retroperitoneal. 2. Movable or Floating Kidney. Eighty-five per cent, of movable kidneys occur in women. The diagnosis may be made from the presence of a movable tumor ha\dng the typical form of the kidney, with convex outer and concave inner borders, and the round, blunt, lower pole. This tumor, hke all renal tumors, usually lies behind the inflated colon. It can be readily brought to the anterior abdominal wah and then can be replaced toward the renal region. An interesting point is that such abnormal mobility is often associated with a general enteroptosis. In addition to the tumor itself, the cases may be divided chnically into three classes : (a) Those in which the tumor is not accompanied by any symptoms referable to the kidney. (b) Those in which the symptoms are those of a drawing pain in the lower abdomen and lumbar region, which may become colicky and radiate do\ATi the ureter, accompanied by evidences of nervous dyspepsia and constipation. The pain decreases when the patient lies down. (c) Those cases which, in addition to the tumor, give the history of recurrent attacks which have been termed "Dictl's crises," and described on page 271. Such an attack is characterized by severe pain, chin, nausea and vomiting. The pain radiates along the ureter. There is but little urine passed during the attack, but following it there is TUMORS OF THE KIDNEY, 313 polyuria. During the attack itself the kidney may be greatly enlarged and tender, but this disappears with the acute syndrome. The urine contains red blood-cells in moderate quantity after the attack, and not during it, as occur in renal colic. Differential Diagnosis. — (a) Movable kidney must be differen- tiated from a corset liver. This is very difficult if they are both present on the right side. Diagnosis is aided by laying the patient on the opposite side, as recommended by Israel, when one can separate the lower edge of the liver, which is always more or less sharp, from the kidney. {h) From the cystic tumors of the liver and enlarged gallbladder. These have a distinct respiratory mobility, and are much nearer the surface than a kidney. They cannot be replaced into the renal region hke a tfoating kidney, and the tumor itself is continuous with the hver, while in the case of the kidney, especially when the colon is inflated, there is an area of tympany between the tumor and the kidney. (c) Tumors of the Colon and Stomach. — Here the history of the case will show, either the symptoms of a pyloric stenosis or an enterostenosis, and there will be more or less emaciation. The inflation of the colon or of the stomach will show more accurately the relation of the tumor to these structures, and in the case of the pyloric tumor, examination of the stomach contents will throw additional Hght. (d) Pedunculated Ovarian and Uterine Tumors. — Their connection with the uterus through the ovarian ligament can be determined by bimanual examination; the floating kidney shows the characteristic form and can be readily replaced. 3. Diseases which are Accompanied by Enlargement of the Kidney. Pyonephrosis and pyelonephritis have been discussed on page 252. Tuberculosis and nephrolithiasis are taken up on page 363. Hydronephrosis, — This causes a tumor which is either constantly prominent, or is intermittent in its presence. This latter form is most often accompanied by floating kidney, recognition of which enables the diagnosis of the condition. The hydronephrotic enlargement of the kidney, like all renal tumors, appears from beneath the costal arch in the lateral aspects of the abdomen. Bilateral palpation enables the tumor to be brought either nearer to the abdominal wall or to become more prominent posteriorly in the space between the last rib and the crest of the ilium. If the hydronephrosis is a recent one, the tumor itself is firm. If it is of longer duration, distinct fluctuation may be found. The tumor lies behind the inflated colon, has a marked degree of mobihty, and its surface is uniformlv smooth. 314 THE ABDOMEN, The differential diagnosis of this form of renal enlargement has been discussed under the subjects: echinococcus of the liver; cystic enlarge- ment of the gallbladder; cysts of the pancreas; ovarian tumors; tumors of the spleen, and neoplasms of the kidney, from all of which it must be differentiated. In renal tumors it may be said, in general, that they lie behind the colon, and this assists in the diagnosis. RENAL NEOPLASMS. Neoplasms of the kidney which may be recognized clinically are of two varieties : 1. Polycystic kid- neys (Fig. 192). 2, Mahgnant tu- mors. I. Polycystic Kid- neys. The diagnosis may be made from the as- sociation of one or more of the following symptoms and physi- cal findings. (a) The presence of bilateral tumors with nodulated sur- faces, having all of the characteristics of renal tumors as given on page 315. Quite rarely a tumor is only to be felt on one side. A palp- able tumor is present in 25 per cent, of all cases. (h) The symptoms of a chronic interstitial nephritis, viz., high- tension pulse, cardiac hypertrophy, large quantities of urine with low specific gravity containing a trace of albumin and few casts. Rarely uremic coma occurs. Differential Diagnosis. — These cases can be differentiated from chronic interstitial nephritis with attacks of hematuria by the fact that the hematuria in nephritis is never as severe as in polycystic disease, and Fig. 191. — Relatioxs of Renal Tumor of Right Side to In- flated Colon. I, Renal tumor; 2, transverse colon; the inflated ascending colon lies in front of the tumor. A similar retroperitoneal condition may be due to unusual position of a pancreatic cyst simulating a renal tumor. TUMORS OF THE KIDXEY. 315 the further fact in that in the latter bilateral, palpable tumors are present in 25 per cent, of the cases. From hydronepJirosis it can be distinguished by the unilateral occur- rence, the smooth surface and greater regularity of a hydronephrotic tumor. 2. Malignant Tumors. The diagnosis of a malignant neoplasm of the kidney may be made from a consideration in each case of five factors which vary greatly in value and in frequency. These are: 1. Hematuria. 2. Pain. 3. Tumor. 4. Cachexia. 5. Metastases. I. Hematuria occurs in about 70 per cent, of all cases as the first Fig. 192. — External View of Coxgexital Cystic Kidney. (See text.) symptom. The hemorrhage occurs spontaneously, independent of exer- cise, may be quite large in amount and last for months. Quite often casts of the ureter, in the form of worm-like clots, are found in the urine. The hematuria of renal calculus is increased or caused by exercise, is never as great in amount as in tumor, does not last as long, and is usually accompanied by cohc. In tuberculosis the hematuria is small in amount, not influenced by exercise, and accompanied by pus and tubercle bacilli in the urine. The hematuria of polycystic kidney is rarely as profuse as that of malignant tumor and does not last as long and is accompanied by the signs of high vascular tension and polyuria. 3i6 THE ABDOMEX. Hematuria in chronic nephritis is rarely as marked; there are never worm-Hke clots, and one finds, in addition, the cardiovascular changes characteristic of this disease. It is impossible to distinguish the hematuria known as essential or idiopathic from that due to mal- ignancy unless tumor or cachexia is present. This form of hemat- uria, however, runs a more chronic course. 2. Pain. This is very rarely the first symptom. When present, it is of a dull, dragging character, referred to the lumbar regions and radiating to the thigh. During an attack of hematuria the passage of the worm-Hke clots causes typical renal colic in the case of renal tumors. 3. Tumors. The majority of cases in adults are hypemephro- mata or sarcomata, while in chil- dren the latter form predomin- ates. The physical characteristics of such renal tumors may be sum- med up as follows : (a) The colon when inflated, lies in front of, or on the inner side of the renal tumor. The latter may be pushed so far inward by a large mass that there is no tym- pany over the tumor when the colon is inflated (Fig. 191). {h) The tumor can best be pal- pated by the bimanual method shown in Fig. 160. By alternately raising the posterior and depres- sing the anterior hand during expiration, the size, consistency, and char- racter of the surface may be ascertained. A second method is to lay the patient on the heahhy side and then palpate bimanually. {c) The general outlines of the kidney may be retained. These are the Fig. 193. — ^Anterior View of a Case of Sarcoma OF THE Kidney in a Boy of Fi\-e. K, Outline of kidney; L, outline of greatly en- larged liver. TUMORS OF THE KIDNEY. 317 concave inner and convex outer borders, and the blunt, rounded, lower pole. When the tumor is quite localized in the lower pole, or very large, the resemblance to the normal shape is absent. {d) Renal tumors cause a fullness in the space between the last rib and the crest of the ihum (ihocostal space). They lie nearer the anterior abdominal wall than does the normal kidney. {e) The tumor may be so large as to occupy almost the entire ab- dominal cavity, as in the case shown in Figs. 193 and 194, so that it is impossible to determine from which organ the tumor has its origin. (/) Benign tumors, with the exception of single and multilocular cysts, seldom give rise to palpable tumors. MaHgnant tumors cause an irregular round mass with a nodular surface and rapid growth. If IS.. Fig. 194. — Side View of Same Child Shown in Fig. 193 (Sarcoma of the Kidney). K, Outline of kidney on the abdominal wall; L, left edge of enlarged liver. retrograde changes or softening are marked, the tumor may feel like a cystic one. {g) Renal tumors when small have a moderate range of passive but practically no respiratory mobility. 4. Cachexia. This is usually not marked until the tumor attains a large size (Fig. 193). Emaciation is more rapid and marked in children (Fig. 193) than in adults. One must distinguish the marked anemia resulting from hematuria from a cachectic condition. Occasionally a renal tumor is accompanied by quite marked elevations of tem- perature. 5. Metastases. There are no symptoms which are characteristic of the growth of the renal tumor into the renal vein or vena cava. One should always bear in mind tlic tendency of malignant tumors to locate secondary foci in bones. This must always be thought of when symptoms occur, referable to the extremities, in a patient suffering. 3l8 THE ABDOMEN. from hematuria and cachexia, since the metastasis may be the first symptom. Differential Diagnosis of Renal Neoplasms. — i. Retroperi- toneal Sarcoma. — These lie nearer the median line and cause but Httle displacement of the colon. When they are large they may involve the kidney so that a differentiation is impossible. 2. Ovarian Tumors. — The pedicle may often be felt to be connected with the uterus or adnexa. The intestines lie above and to its outer side (Fig. 1 80). The ovarian tumor, unless very large, can be traced to the pelvis, while a renal tumor appears to come from beneath the costal arch and causes bulging of the loin. 3. Splenic Tumors. — These, if large or when the characteristic shape is obliterated, may be impossible to differentiate (Fig. 189). If smaller, the characteristic notched edge and smooth surface aid in distinguishing them. In addition, the splenic tumor lies in front of the inflated colon and is not accompanied by hematuria. 4. Tumors of the Liver. — When the renal tumor is moderately large a zone of resonance is found between it and the liver. The renal tumor causes more bulging of the lateral aspects of the abdomen, is accompanied by hematuria and blood- casts of the ureter. Hepatic tumors lie more anteriorly and in front of the colon, unless the latter is adherent to their anterior surface. ASCITES. The presence of free serous fluid in the peritoneal cavity may either simulate or obscure the existence of abdominal tumor so that it is neces- sary to recognize the physical signs caused by such fluid. These are: 1. Widening of the abdomen. 2. A wave-like impulse, upon tapping with the fingers of one hand, felt by the other hand laid flat upon the opposite side of the abdomen. While the patient is lying on his back percussion shows the median portions to be tympanitic (Fig. 180). This is the opposite of the percus- sion findings in ovarian cyst (Fig. 180), unless the latter is accompanied by ascites. When the patient lies on one side, the opposite flank becomes tympanitic, but this changes to dullness when he is rolled upon his back again. The diagnosis of an ascites is confirmed by inserting a trocar in the median line midway between the navel and symphysis pubis, and ob- taining a clear straw-colored fluid of low specific gravity containing a small amount of albumin. ASCITES. 319 In tuberculous and carcinomatous processes the fluid is at times hemorrhagic, but this is inconstant. In these cases a multilocular con- dition may exist and more than one puncture may be necessary to obtain the fluid. In chylous ascites the fluid is milky. Having ascertained the presence of an ascites, one must attempt, either before or after the removal of the fluid, to de- termine its cause. This may be local or gen- eral. Local: (a) Obstruction of the portal circula- tion, due to: Cirrhosis of the liver. Neoplasms of the liver. Abdominal tumors which compress the inferior vena cava or portal vein. {b) Tuberculous or simple prolifera- tive peritonitis. (c) Neoplasms of the peritoneum. (d) Tumors of the ab- domen — especi- ally ovarian cysts, uterine fibroids impact- ed in the pelvis, etc, (e) Obstruction of receptaculum chyli or duct leading from it. General: (a) Cardiac affections. (b) Renal diseases. (c) Chronic pulmonary diseases such as emphysema or sclerosis. Fig. 195. — The Areas of Dullness in a Case of Encap- sulated Intraperitoneal Fluid. This illustration is the front view of the patient shown in Fig. 196. I, Indicates the size of the encapsulated abscess, which was of a tuberculous nature, lying between the abdominal wall and the agglutinated coils of intestines within the peritoneal cavity, extending upward between the right lobe of the hver and the thoracic wall. 2, Indicates the area of external prominence on account of which the case was at first thought to be one of hydronephrosis. 320 THE ABDOMEX. TUMORS DUE TO INFLAMMATORY EXUDATES OR TO TUBERCULOUS PERITONITIS. Tumor-like masses may follow many of the acute and chronic ab- dominal affections, especially appendicitis and inflammations of the female pelvic viscera. The tumor- like induration around some gastric ulcers is referred to on page 335. Massive exudates often bind adjacent coils of intes- tine together in such a man- ner as to closely simulate neo- plasms on palpation. The history of a preceding inflam- mation is of the greatest aid in making a diagnosis in these cases. Often some tender- ness and muscular rigidity coexist. Tuberculous peritonitis is more fully discussed on page 343. It may give rise to tumors simulating those bav- ins: their origin from the var- ious viscera referred to in this section in one of four ways. (a) Encapsulated exu- dates (see Figs. 195 and 196). (&) Through puckering of the omentum. This causes a transverse, hard, elongated tumor, lying just above the umbilicus, although it has been found in the right iliac region. (c) In an occasional case, after an ascites has been tapped one can feel the tumor due to contracted and adherent coils of intestine (Fig. 197)- (d) The presence of tumor-like masses in children due to enlarged tuberculous mesenteric glands with or without accompanying ascites. The diagnosis may be made if there are tuberculous foci elsewhere, especially of the cervical lymph-nodes. When this is accompanied by Fig. 196. — Enxapsulated TuBERCuLors Peritonitis. Shaded area indicates the false membrane found at the time of operation, which separated the abscess ca\Tty from the stomach and intestines, which were adherent to each other, and pushed to the posterior and left portions of the abdominal cavity. This is the side view of the same case represented in Fig. 195. TUMORS DUE TO ANEURYSMS OF ABDOMINAL AORTA. 32 1 emaciation and evening rise of temperature, the diagnosis is rendered almost certain, but both of these may be absent, as in the case shown in Figs. 195 and 196. The tumors are often accompanied by pains and digestive disturbances in tuberculosis. One should never omit a rectal and vaginal examination. The history of tuberculous environments or of eating the flesh or milk of tuberculous cattle is of value also. TUMORS DUE TO ANEURYSMS OF THE ABDOMINAL AORTA OR ITS BRANCHES. Aneurysms of the abdominal aorta and its larger branches may give rise to palpable tumors which, in general, are readily recognized. When Tubercles. Fig. 197. — Coils of Intestine in a Case of Tuberculous Peritonitis. The label pseudomembrane leading to a cross shows how these false membranes bind the different coils of intestine to each other. The serous surfaces of the various coils show innumerable tubercles covered by this false membrane. grasped between the thumb, on one side, and the fingers on the other (Fig. 385), these tumors have an expansile pulsation and a systolic thrill. Auscultation shows a systolic murmur. These signs may, however, be rather indistinct if the aneurysmal sac is nearly obliterated. Under such circumstances the tumor can be recognized as being aneurys- mal only by exclusion (Fig. 199). 322 THE ABDOMEN. In the majority of cases it is impossible to diagnose aneurysms of the coeHac axis, or its branches, or of the renal arteries. When palpable, however, they show the same signs as do those of the aorta. The writer recalls one case of aneurysm of one of the branches of the superior mesenteric artery which caused a very mobile tumor whose nature was not recognized before operation. Aneurysms of the iliac arteries are often easily palpable (Figs. 198 and 199). Those of the external iliac cause a firm, immovable tumor in the iliac fossce whose nature can be determined by the pres- ence of the characteristic ex- pansile pulsation, of a thrill and murmur. Differential Diagnosis. — An unusually marked pul- sation of the abdominal aorta occurring in neurasthenics is often erroneously diagnosed as an aneurysm. It lacks the typical expansile pulsation of an aneurysm and the thrill is absent. Tumors of the pylorus or pancreas lying over the ab- dominal aorta may have ap- parent pulsation through the transmission to them of the arterial movements. When the patient is placed in the knee-chest position, these tumors of intraperitoneal ori- gin lose this pulsation. They lack the expansile character of aneurysm, and one can usually recognize their nature by the other signs, such as the tests, etc., des- cribed. Pulsating tumors filling up the entire ihocostal space and lateral ab- dominal regions are usually due to the rupture of an abdominal aneurysm into the retroperitoneal tissues. Fig. 198. — View feom Right Side of Tumor of Abdomen (T) DUE TO AN Aneurysm of the External Iliac Artery. Note the prominent varicose veins over the region of the tro- chanter. This is the same case as shown in Fig. 199. TUMORS ARISING IN THE PELVIC VISCERA. 323 ABDOMINAL TUMORS HAVING THEIR ORIGIN IN THE PELVIC VISCERA OR BONES. Only those tumors are mentioned in which the enlargement is sufficient to cause the growth to rise out of the pelvis. I. Distended Urinary Bladder. — In both sexes the enormously distended urinary bladder (Fig. 178) has been mistaken for a neoplasm. Ascites, an encapsulated exudate, and ovarian cysts are also among the tumors with which it has been confounded. The diagnosis may readily be made from the history, shape of the tumor, and its position in the median line (Fig. 178), aided, where neces- sary, by catheterization, which is followed by the disappearance of the tumor. Wherever any question exists, and, in fact, to aid palpation of Fig. igg. — Lateral View of Tumor of Abdomen due to Aneurysm of the External Iliac Arterv Causing Prominence in Right Iliac Region. Note the extensive varicose veins along the outer aspect of the thigh. tumors of the lower half of the abdomen in general, the patient should be catheterized. 2. Osteosarcomata. — Sarcomata arising from the inner aspect of the OS innominatum must be suspected, if the tumor is found in the iliac fossa, is fixed, hard, and gives the history of rapid growth. 3. Neoplasms of Lymph-nodes. — Tumors arising from the lymph- nodes lying along the pelvic brim are rare and are accompanied by evi- dences of a primary growth or by inflammatory symptoms. They may often be palpated through the rectum or vagina. 4. Tumors arising from the pelvic viscera of the female are the following: 1. Pregnant uterus. 2. Large uterine myomata which extend into the abdominal cavity. 324 THE ABDOMEX. 3. Pedunculated uterine and ovarian tumors. 4. Large ovarian tumors. The possibility of the presence of the first named condition must never be forgotten in the diagnosis of tumors of the lower half of the ab- domen and the signs of pregnancy must be sought for. Large uterine myomata are in general of round form and firm consistency. They may, however, be quite soft and give a sense of fluctuation. They can usually be moved with the body of the uterus and if submucous are accompanied by severe menstrual and inter- menstrual hemorrhages. When interstitial, no symptoms are produced except those due to an enlarged uterus. Pedunculated Ovarian and Uterine Tumors. — These may have such a long pedicle as to permit the tumor to be moved or palpated, as the case may be, from the pelvis to the costal arch, unless they are fixed by adhesions, under which circumstances it is almost impossible to recognize their nature before operation. If not thus fixed, bimanual examination will often reveal the pedicle and its relation to the pelvic viscera. Larger Ovarian Tumors. — These, unless colossal, can be recog- nized by the fact that they rise out of the pelvis, and their pedicle can often be traced toward the uterus, especially by bimanual examination. They cause contrasting physical signs to those of ascites unless ac- companied by the latter. These signs are prominence and dullness over the pubes and in the median regions, but tympany in the flanks (Fig. 180). The diagnoses of the various smaller pelvic tumors arising from the uterus and adnexa are not considered here, as they are fully discussed in the special books on gynecology. Diseases of the Esophagus, stricture of the esophagus. The esophagus extends from the level of the cricoid cartilage to the cardiac end of the stomach. The beginning is 15 cm., the termination 40 cm., from the teeth (Fig. 200). There are certain points where the esophagus is normally constricted, and these must be borne in mind when an examination with bougies for a suspected stricture is made. These narrow points are (Fig. 200) : 1. At the beginning, opposite the cricoid or 15 cm. from the teeth. 2. Opposite the bifurcation of the trachea or 26 cm. from the teeth. 3. Where it penetrates the diaphragm or 37 cm. from the teeth. STRICTURE OF THE ESOPHAGUS. 325 Methods of Examination. — The most frequently employed method of examination for esophageal stricture is the use of graduated bulbous bougies passed in the manner shown in Fig. 201. Instead of the flexible bougie with olive tip, one can use a gum-elastic stomach-tube. The ■~D Fig. 200. — Normal and Pathologic Conditions of the Esophagus. In all of the diagrams B represents the bifurcation of the trachea into the two main bronchi: D, is the diaphragm., aijd S, cardiac end of the stomach. I, Normal esophagus: i, Showing the normal point of narrowing at its junction with the pharymx; 2, opposite the bifurcation of the bronchi; 3, at the diaphragm. II, Loca- tion of most frequent diverticula of the esophagus: H, Cervical form of pulsion or pressure diverticulum; M, location of traction diverticulum opposite bifurcation of trachea; L, location of diverticulum close to car- diac end of stomach. Ill, Sacculated condition of esophagus or so-called idiopathic dilatation as the result of spasm of the cardiac end of the esophagus (cardiospasm). IV, Diagrammatic representation of most frequent seats of stenosis or stricture of the esophagus: A, Arch of aorta; i, stenosis as a result of carcinoma of the lower end of pharynx and beginning of esophagus; 2, stenosis as a result of pressure from tumors of the neck; 3, stenosis as a result of aneurysm of the arch of the aorta; 4, stenosis as a result of caustic or lye strictures; these latter may extend along the entire length of the esophagus; 5, stenosis as a result of carcinoma of the lower end of the esophagus and cardiac end of stomach. patient should be seated on a low chair with head bent backward. Hold- ing the patient's tongue down with the index-linger of the left hand, the bougie is passed directly back to the posterior wall of the pharynx, where the resistance prevents further progress in that direction. The bougie or 326 THE ABDOMEN. gum-elastic stomach-tube is then directed downward, great care being employed to avoid perforating a carcinomatous area or a diverticulum. It is advisable to begin Vvdth a large size and reduce the caHber if it is impossible to pass the first one. The esophagoscope has been employed for the purpose of locating strictures by Gottstein and others, but re- quires great dexterity and famiharity with it, so that for general pur- poses we rely on the above two methods. When a genuine resistance is met the bougie is withdrawn and the distance of the stenosis from the teeth is noted. Other methods of locating strictures, such as auscultation posteriorly while the patient swallows water, are seldom employed and are not so Fig. 201. — Method of PAssmo Esophageal Bougies in Order to DETERiONE the Le\'el of a Stric- ture. Note how the patient's head is held slightly backward, the left hand being placed upon the forehead, while the right hand grasps the bougie in a manner similar to that of holding a penholder, no force being used. reliable as the passage of bougies. In every case it is advisable, in addi- tion to instrumental examination, to insert the index-finger into the pharynx, because one may be able to palpate a malignant growth at the beginning of the esophagus. An attempt should be made to recognize not only the location but also the nature of the stricture if one exists. Within recent years bismuth and similar substances which give a shadow in a skiagraph have been employed to locate strictures of the esophagus, and also in cases of diverticula and dilatation. The patient is given about one ounce of bismuth subnitrate mixed with bread or potato and instructed to swallow it. The substance lodges above the point of stenosis, as shoT\'n in Fig. 202, causing a distinct shadow in STRICTURE OF THE ESOPHAGUS. 327 cases of dilatation. One gets a spindle-shaped shadow corresponding to the extent of the dilatation. Another method, to be referred to below, is also used, and this consists in having the patient swallow a bag filled Fig. 202. — ^X-RAY OF a Case of Stp.icture of the Esophagus Opposite the Bifurcation of the Trachea. The outlines of the bismuth shadow have been traced in white. with shot, which gives rise to a shadow at the point of stenosis or within the sac of the diverticulum. Diagnosis. — The diagnosis of esophageal stricture in general may- be made from the following: 328 THE ABDOMEX. 1. History of difficulty in swallowing accompanied by the regurgita- tion of food or mucus, often mixed with blood. 2. History of some etiologic factor mentioned below under the head of cicatricial or extra-esophageal or malignant causes. The exclusion of a neurotic cause of the stenosis must always be made. 3. The results of the local examination with the bougies, stomach- tubes, esophagoscope, or an .r-ray after bismuth has been swallowed. The diagnosis of the cause of the stricture may be made by excluding the following in their order: 1. Cicatricial Strictures. — These give the histor\- of having swallowed caustic liquids or having had some disease which could produce esopha- geal ulcerations, such as syphilis or typhoid fever. The bougie meets a firm resistance which responds readily to treatment by graduated bougies. 2. Strictures due to Pressure jrom External Causes. — This group in- cludes pressure upon the esophagus from aneurysm of the arch of the aorta, enlarged cervical or retrosternal goiter, especially when mahgnant, enlarged cervical and bronchial glands, tumors of the neck or mediastinal tissues, rarely pericardial effusions, and lastly by esophageal diverticula. It is unnecessar}' to consider the diagnosis of these various extra- esophageal causes of strictures here, as they are discussed under the re- spective headings. 3. Carcinomatous or Malignant Strictures. — This is by far the com- monest cause of stricture of the esophagus in patients above forty, and especially after the age of fifty years. The dysphagia common to all strictures appears in carcinoma, gradu- ally accompanied by progressive emaciation and loss of strength. The other s}Tiiptoms x3lTX according to the situation of the carcinoma. (a) If at the beginning of the esophagus (Fig. 200) there is immediate regurgitation of the food and early enlargement of the cervical lymph- nodes. In one case recently seen the patient consulted the writer in re- gard to the tumor of the neck before the dysphagia had become suffi- ciently marked to attract his attention. (b) If the cancer is situated at the level of the bifurcation of the trachea, hoarseness and aphonia are marked. (c) If situated close to the cardiac end the regurgitation of food occurs much later, often ten to fifteen minutes after being swallowed. The bougie is arrested at the beginning of the carcinoma and no force should be employed in passing through it. A sudden improvement in the stenosis symptoms, points to ulceration of the cancer. Late sequelae of malignant stricture are perforations into the pleural ca\'itv or mediastinum. DIVERTICULA OF THE ESOPHAGUS. 329 4. Spasmodic Stricture. — This fourth variety of stricture is com- paratively rare and can usually be distinguished from the cicatricial, extra-esophageal, and malignant forms by the history and the physical examination. The spasmodic strictures occur in nervous hysterical women, but may occur in elderly men, and are often associated with hypochondriasis or true hysteria. The bougie is often temporarily arrested at the point of spasm, but by waiting a short time it can be passed through the stricture readily, especially under anesthesia. DIVERTICULA OF THE ESOPHAGUS. There are two varieties: 1. Traction diverticula situated on the anterior wall opposite the bifurcation of the trachea. They are caused by cicatrices resulting from bronchial lymph-node or pleuropericardial inflammation, drawing the anterior wall out. This form cannot be diagnosed unless, as rarely occurs, food collects within the sac so that a pressure diverticulum is formed. 2. Pressure diverticula occur in three places : (a) In the pharynx, causing at times a tumor in the neck, referred to on page 177, which can be emptied when filled with food. This is the most frequent form. {h) At the bifurcation of the trachea developing from a traction diverticulum. (c) Just above the diaphragm. The diagnosis of a diverticulum of the pharynx may be readily made if there is a history of a tumor of the neck, most often. on the left side, which develops during eating, can be emptied by pressure, and is ac- companied by the regurgitation of food. A bougie is arrested at the cricoid and may be passed into the sac and freely moved about, so that the tip can be felt in the neck. If situated lower down, other means of diagnosis are employed, and the condition must be differentiated from stricture and dilatation of the esophagus, because in all three the symp- toms of regurgitation of food ar£ present. The methods of diagnosis at present employed to differentiate these three varieties of pressure diverticulum are : 1. The use of bismuth or similar shadow-producing substances and a 'skiagraph. If the patient is allowed to swallow a bag of bird-shot or a mixture of bismuth and bread, it often enters the diverticulum and gives rise to a distinct shadow. 2. A bougie enters the opening of the diverticulum, if the latter is 33© THE ABDOMEN. full, and is arrested there, but meets with no obstruction and passes into the stomach, if the sac is empty. This intermittent arrest of the bougie is characteristic of deep-seated diverticula. One tube can at times be passed into the diverticulum and a second alongside of it into the stomach. If different colored fluids are poured into them separately, they will return unmixed. 3. The esophagoscope often shows the opening of the diverticulum, but, as stated above, its employment requires considerable skill and practice. A deep-seated diverticulum is distinguished from a stricture by the fact that the arrest of the bougie is intermittent in the former and constant in the latter. (See method i, above.) It may be differentiated from a diffuse dilatation either by the skiagraph or the Rumpel test, which is as follows : A tube with lateral openings is passed into the stomach, while a second one is passed into the diverticulum. If there is dilatation, colored fluid poured into the tube at the point of enlargement will flow through the lateral openings into the stomach. If a diverticulum is present noth- ing will flow out of the tube in the stomach, while from the tube in the diverticulum all the fluid poured in will be recovered. IDIOPATHIC DILATATION OF THE ESOPHAGUS. This frequently follows a spasm of the lower end of the esophagus. The lumen may become enormously dilated, so that when a bougie is passed it meets with no obstruction but has a very wide range of motion. A skiagraph taken after the ingestion of bismuth often shows a spindle- like shadow. The esophagus wiU hold 500 Cc. of fluid uistead of 100 Cc. of fluid. In the majority of cases the patients suffer from diffi- culty in swallowing, and from regurgitation of food soon after eating or several hours later. There is great fetor and a feeling of oppression in the thorax which is only relieved by vomiting. The regurgitated food contains no HCl, but an excess of lactic acid. FOREIGN BODIES IN THE ESOPHAGUS. These may be divided into those which are rough and those which are smooth. The former cause both obstruction and injury to the wall of the esophagus, while the latter only cause obstruction. If situated high up near the opening of the glottis, foreign bodies, like chunks of meat, may cause asphyxia. If they are smaller they give rise to attacks of cyanosis and suffocation. If the foreign body is sharp it causes pain which is often referred to the sternum. SURGICAL DISEASES OF THE STOMACH. 33I The diagnosis may be made from (a) the history, in the majority of cases; (b) examination by the various methods to be mentioned; and (c) the symptoms of dysphagia, pain, and appearance of periesophageal abscesses due to perforation of the wall and infection of the surround- ing connective tissue. The methods of examination are (a) the passage of an olive-tipped bougie, which is arrested where the foreign body is lodged unless its convex surface lies in the concavity of the anterior wall. (b) Esophagoscopy. (c) A skiagraph is very valuable if the foreign body is a metallic one. (d) The finger should be inserted into the beginning of the esophagus and the laryngeal mirror used. Other Abdominal Conditions. In the preceding sections an effort has been made to group affections as they present themselves when we are called to the bedside of a patient to make a diagnosis. As stated in the preface, it was thought by the author that such a grouping more nearly meets with clinical conditions than would one in which the injuries or diseases of each viscus were discussed separately. It is impossible, however, to consider every condition under the heads of Traumatisms, Acute Affections, and Tumors of the Abdominal Viscera, so that it will now be necessary to take up the remaining dis- eases which are of interest from a surgical standpoint. SURGICAL DISEASES OF THE STOMACH. Dilatation of the Stomach. This occurs acutely, as a postoperative condition (see Chapter on Post-operative Complications), or in a chronic form. The latter results from congenital or acquired stenosis of the pylorus. In congenital stenosis the diagnosis may be made from the history and the physical examination. It usually begins in the first weeks of life. The baby is unable to retain any or very little food and vomits very frequently. If the emesis is accompanied by diarrhea with much mucus and undigested milk in the stools, the condition must be differentiated from gastro-enteritis. It is possible to see the peristaltic waves passing across the epigastric and umbilical regions when the stomach is filled. If in addition to the constant vomiting and visible peristalsis one is 332 THE ABDOilEX. able to palpate a mass just below the right costal arch corresponding to the hypertrophied pylorus, the diagnosis is certain. Unfortunately, in many of the cases the peristalsis and tumor are not detected until the disease is well advanced. This condition must always be borne in mind when there is a histor}^ of repeated vomiting immediately after the m- gestion of food in emaciated infants, whether breast-fed or bottle-fed. Acquired stenosis is most often the result : {a) Of stricture or adhesions following the healing of a round ulcer. (h) Of mahgnant disease of the pylorus. (c) Of gastric atony. The diagnosis of gastric dilatation, whether congenital or acquired, is readily made from the following: Vomiting is the most prominent symptom. At varying intervals, ordinarilv every two or three days, an enormous quantity of Hquid mixed w^ith undigested food, and of an offensive odor is brought up. In the intervals there is complaint of oppression after eating, eructations of gas, and thirst. Tetany may occur as an early symptom. When the stomach is full one can easily demonstrate a splashing sound on succussion. The outlines of the distended organ are often \dsible and peristaltic waves can be seen passing across it toward the pylorus. VChen the stomach is inflated with air the outlines become verv- plain. In gastroptosis both the lesser and greater curvatures are at a lower level, while in dilatation the lesser remains almost normal, ahhough the greater may even be as low as the symphysis pubis. A history of manv vears' duration, preceded by severe pain after eating and either melena or hematemesis, speaks for ulcer as the cause of the obstruction. Rapid emaciation, absence of HCl in the vomit, palpation of a tumor, speak for malignancy. Adhesions rarely cause a marked degree of dilatation. Gastric and Duodenal Ulcer. Symptoms. — In many cases the presence of this condition is not suspected until there is hemorrhage from the stomach or bowels or symptoms of perforation occur (page 266). In other cases there is a characteristic group of symptoms from which the diagnosis is made. They are as follows : Pain. — This is either felt soon after the ingestion of food in gastric, or one to two hours later in duodenal ulcer. The pain is usually well localized in the epigastrium, but may radiate to the back and sides. Dur- ing the painless interv^al there is tenderness on pressure over the epi- gastrium. SURGICAL DISEASES OF THE STOMACH. 333 Hemorrhage. — This may be latent and only be found by examination of the stomach contents. In many of the cases of acute ulcer, the hemor- rhage is profuse and is vomited as bright red fluid blood. This may oc- cur only once or be repeated at intervals for years. In duodenal ulcer the patient may suddenly collapse, or feel faint and pass large quanti- ties of tarry blood in his stools. Dyspeptic Symptoms, Nausea and Vomiting. — The degree of the symptoms of indigestion varies greatly. They may be insignificant or very marked. Vomiting one to four hours after eating is frequent in gastric ulcer, and in both the stomach contents frequently show hyper- chlorhydria. Differential Diagnosis. — Gastralgia. — The area of tenderness is more locahzed in ulcer and present during the intervals of the attacks of pain. Hyperacidity is a more constant finding in ulcer, while in gastralgia it may be present or there be deficient HCl. In many cases of ulcer there is a history of hemorrhages and of dilatation. Dyspeptic symptoms and vomiting in the intervals of pain are more characteristic of ulcer. Carcinoma oj the Stomach. — This is considered elsewhere (page 335). Epigastric Hernia. — This is referred to on page 420. Gallstones. — The attacks of pain, as a rule, occur independently of the ingestion of food, are located over the region of the gallbladder, and are accompanied by rigidity. The attack of bihary colic begins suddenly and the pain is far more severe than that of ulcer. It radiates to the right shoulder, and the vomiting which accompanied it persists after the stomach is empty. If the ulcer, as is most often the case (Fig. 203), is situated on the posterior wall near the pylorus, there is a localized tender spot between the right costal margin and middle line, unless a gastroptosis exists, while in gallstones the tenderness and pain are further to the right (Fig. 167). Ulcer of Stomach versus Ulcer oj Duodenum. — It is almiost impossible to distinguish these clinically. Duodenal ulcers are more frequent in men after middle age, the pain occurs one to two hours after ingestion of food and is referred to the j-ight hypochondrium. Intestinal hemor- rhage occurs after gastralgic attacks with hematemesis in duodenal ulcer. But all of these may occur in gastric ulcer (which, however, is more common in women under thirty), so that an absolute differentiation is impossible. Diagnosis of the Complications of Gastric and Duodenal Ulcer. — I. Perjoration was referred to in the section on acute abdominal affections, page 266. 334 THE ABDOMEN. 2. Perigastric Abscess due to Perforation (Left Subphrenic Abscess). — The diagnosis is dependent on the history of the ulcer, as given above, followed by acute symptoms of a localized peritonitis, usually of a left subphrenic abscess. There is a history of perforation followed by ir- regular fever, tenderness over the left upper quadrant of the abdomen combined with physical signs over the lower part of the left side of the chest, as in empyema. Occasionally induration and tenderness are present in the epigastrium. If a retroperitoneal abscess form, the pus may burrow toward the lumbar region and cause fluctuation here. Gas Fig. 203. — MULTIPLE' Ulcers of Posterior Wall of Stomach. P, Pylorus. By following the illustration downward from this letter, one can note the rather sharp de- marcation between the gastric mucous membrane, on which the ulcers are situated, and the duodenum, shown at D. I, 2, 3, and 4 are typical round ulcers showing great variation in size, situated on the posterior wall of the stomach. is more frequently present in left than in right subphrenic abscess, so that above the dullness there is tympany. Unless there is an accompany- ing pleuritic effusion, breath sounds are heard above the upper level of dullness and there is respiratory mobility. The three zones of normal lung resonance, tympany and dullness are well shown in Fig. i66. 3. Hour-glass Stomach. — This follows cicatrization of an ulcer. The diagnosis may be made from the following signs and tests as given by Moynihan : First, when fluid is introduced into the stomach it seems to disap- SURGICAL DISEASES OF THE STOMACH. 335 pear altogether, and is not returned through the tube. Second, when the stomach is washed out, until the fluid returns clear, there is a sudden, unlooked-for gush of foul or often putrid fluid. Third, on distending the stomach with carbon dioxid, the bubbling and gushing of fluid through a narrow chink can be heard with a stethoscope. Fourth, there may be a distinct visible or palpable sulcus separating two dilated cavities. Perigastric Adhesions. — These may be recognized by symptoms of chronic indigestion or pyloric obstruction of slight degree, by slight tender- ness over the epigastrium, and the occasional presence of palpable tumor. There is often a history of gastric ulcer (in 40 per cent, of the cases) or of gallstones, or less frequently of tuberculosis. The tumor may re- semble that of cancer, but is never accompanied by the progressive emaciation of the latter condition. The course is very chronic and is frequently accompanied by evidences of biliary stasis and absorption. Carcinoma of the Stomach. The presence of this condition is diagnosed if, in a patient above the age of forty, with or without the history of ulcer, signs of digestive dis- turbances appear accompanied by pain, anemia, loss of weight, and vomiting. The most important points in making a diagnosis are: {a) The history of steady, progressive loss of weight. {h) The presence of a secondary anemia, both red corpuscles and hemoglobin being reduced. (c) Pain. This is an early and important symptom according to Osier, and was present in 130 to 150 cases. At first only a heaviness after eating is noticed, but later it is of a dull, gnawing character re- ferred to the epigastrium. There is marked local tenderness. {d) Vomiting. This is also very constant. It occurs earliest when the tumo'r is near the pylorus, from one to two hours after the taking of food. At first it is infrequent, but later is almost constantly present. (e) Hemorrhage. This rarely occurs as bright red blood, but most frequently in smaller quantities, giving the vomitus the typical "coffee- ground" appearance. (/) Stomach contents. An analysis of the stomach contents after a test meal has been given should be made on several occasions at short intervals in order to draw accurate conclusions. The constant absence, or great reduction of hydrochloric acid and the presence of lactic acid are strongly indicative of cancer. Unfortu- nately, these data are often so late in their appearance as to be of little value unless present quite early. 00^ THE ABDOMEN. On the other hand, carcinoma may exist although hydrochloric acid is present. The latter is the condition frequently found in cases of carcinoma developing upon a round ulcer (Fig. 204). The presence of the Oppler-Boas bacillus is of shght value, but the detection of lactic acid in the stomach contents after a Boas test meal is of greater value. The constant presence of blood intimately mixed v^ith the gastric contents is also of great importance, especially if vomited alone; as hydrochloric acid is absent in cases of chronic gastritis or atrophy of the mucosa, the value of the presence of blood is apparent. Fig. 204. — CARCiNOiiA of Stomach Developing upon Round Ulcer. This is the primary tumor whose metastases are seen in the liver in Fig. 185. C, Observe the sharp de- marcation between the carcinoma and the surrounding normal mucous membrane of the stomach. D, Mucous membrane of duodenum. Observe the pro.ximity of the carcinoma to the pylorus. G, Lymph-nodes along gastrohepatic omentum. ig) Tumor. This is the most important symptom, but, like the changes in the stomach contents, is often only present at a late stage. The surface is usually smooth. Unless adhesions exist a tumor of the stomach is freely movable (Fig. 181) and is best felt when the stomach is empty. Usually the tumor is located in the epigastric or umbilical regions, but in gastroptosis may be in the right iliac region (Fig. 183). The presence of an ascites may render the palpation of a tumor impossible until the fluid is aspirated, and this should, of course, be done. GALLSTONES. 337 GALLSTONES. Many cases of cholelithiasis are either not recognized during life or they are found as an accessory condition in operations for other intra- abdominal lesions. Cases in which a diagnosis is possible, occur clinically in different forms, as follows : 1. Those seen during an attack of biliary colic or of empyema of the gallbladder. 2. Those showing evidences of a complete occlusion of the cystic duct by a calculus. 3. Symptoms of common duct calculi with or without accompanying infection. 4. Cases seen in the interval between active symptoms pointing to the bile-passages. The diagnosis of the first and second classes of cases has been re- ferred to on pages 247 and 297, respectively. 3. Common Duct Stones. — A stone passing through the common duct may give rise to colic which cannot be distinguished, during the at- tack, from that due to the passage of one through the cystic duct. The most frequent location for common duct calculi is near the ampulla. The diagnosis must be made between one of two forms, according to whether the lumen is completely or incompletely occluded. (a) Those causing complete obstruction. These are rare and may be recognized by the fact that the jaundice is deep and constant and there are no evidences of intrahepatic infection, as in the next group. They must be differentiated from new-growths pressing on the common duct by the absence of emaciation, and of symptoms indicative of cancer of the pancreas (page 303) or of the pylorus (page 335). (b) Those causing incomplete obstruction due to a ball-valve action of the calculus. This is the more frequent form and is often accompanied by attacks of pain and chills at irregular intervals followed by high fever and a sweat. Jaundice becomes marked and the liver may be enlarged and tender. In a late stage the gallbladder itself is contracted in the majority of cases. A ball-valve-like common duct stone may, however, occur without infection of sufficient intensity to cause symptoms. The diagnosis may then be made from the history of previous attacks of biliary colic and by variations in the intensity of the jaundice. Differential Diagnosis. — These attacks of rigors, etc., so closely resemble those of malaria that a mistake in diagnosis has often been made. Malarial paroxysms occur with more regularity and are less frequently 338 THE ABDOMEN. accompanied by jaundice, which, when present, is not deep. Nor is pain over the hypochondrium present, and unless quinin has been given, Plasmodia can be found. There is also no leukocytosis in malaria, and the spleen is enlarged. Exceptionally plasmodia are not found until quinin has been given. The presence of jaundice between the chills, and of clay-colored stools, should always direct attention to the possibility of gallstones, for which the stools must be searched. The diagnosis of suppurative cholangitis has already been referred to (page 249). The septic intoxication is more marked, the fever is of a more continuous type, the liver is enlarged and tender, and recovery does not occur. 4. Diagnosis During the Interval. — It is this class of cases in which the recognition of the condition is often most difficult, for one has only the history and the results of the physical examination upon which to make a diagnosis. History. — This is of the greatest importance, since many cases as- sumed for years to be gastralgia, indigestion, or intestinal colic, or even gastric ulcer, are now found to be cases of gallstones. The history should be directed toward the following points : 1. Has pain been present at any time? If so, one should secure a detailed description of the attacks and compare it vnth those of typical biliary colic. Such paroxysms of pain are less frequently obsen-ed than is a dull aching pain referred to the gallbladder. This dull pain is increased by taking food, but is relieved by vomiting or by pressure over the gall- bladder. The biliary colic pain is acute in its onset, very severe, and disappears suddenly, while the dull pain above referred to is more or less continuous. Radiation to the shoulders occurs in both of these varieties of gallstone pain. 2. What alimentary symptoms have accompanied the pain ? In the majority of cases there is a history of nausea and vomiting, accom- panying the more severe variety of pain, or there is a histor}^ of long- continued digestive disturbances with dull pain over the gallbladder. Jaundice occurs so rarely in gallstones that its absence in the history must not permit one to think of excluding gallstones. This is especially true of stones in the gallbladder and cystic duct. Jaundice, if of slight degree, is difficult to detect. A good plan is to look at the roof of the mouth at the back of the hard palate, where it is often visible, if no- where else. It is also important to inquire in regard to the presence or GALLSTONES. 339 absence of bile in the stools. The jaundice due to carcinoma of the head of the pancreas or to a calculus completely obstructing the com- mon duct is persistent and progressive. 3. Have fever, chills, and sweats been present at any time? Ir- regular paroxysms of these three symptoms, especially if accompanied by jaundice which varies greatly in degree, speak for common duct stone. Continued fever with but slight remissions indicates an empyema of the gallbladder. Physical Examination. — Palpation of the Gallbladder Region. — Fig. 205. — Method of Examination to Elicit Tenderness of Gallbladder (Moynihan). One can often detect hypersensitiveness of the gallbladder by pressing the fingers down upon the gallbladder as shown in Fig. 179 or by the method described by Mo}Tiihan and shown in Fig. 205. In the latter procedure, while sitting to the right of the patient, the left hand is laid over the right side of the patient's chest so that the thumb lies along the costal arch. As a deep breath is taken the thumb is pressed upward toward the under surface of the liver. In addition to the hypersen- sitiveness there is frequently rigidity of the upper end of the right rectus. Diagnosis of the Location of Calculi if Arrested Temporarily or Permanently.— ^7o;ie5 in the Gallbladder. — These cither cause no 340 THE ABDOMEN. symptoms or they are those of an acute or a chronic cholecystitis. The diagnosis of the former is taken up on page 246. That of the latter is made from the presence of the dull, localized pain just described above, and digestive disturbances. Stones in the Cystic Duct. — These cannot be distinguished from those of the gallbladder unless a tumor is palpable which can be recog- nized as due to a hydrops of the gallbladder (page 297), and this is not frequent. During the passage of a stone from the gallbladder into and through the cystic duct the symptoms are, for both, those of biliar}^ colic. Stones in the Common Duct. — Pain accompanied by distinct rigors, irregular fever, jaundice which varies in degree, and emaciation are characteristic of these calculi. Stones in the hepatic duct or intrahepatic bile-passages cannot be recognized as such clinically. APPENDICITIS (CHRONIC). The diagnosis of acute appendicitis and its differentiation from other abdominal affections has been discussed on page 260. There is a form of inflammation of the appendix whose clinical course differs some- what from the acute. In this class of cases the patient has had an acute attack which was either not diagnosed or not operated upon. From time to time attacks of pain in the right iliac region occur of just sufficient severity to direct the patient's attention to them. The pain is usually of a dull aching character and incapacitates the patient for work for a day or so. It may be sharp and colicky in character, lasting, however, only a few minutes. To the latter class the term appendicular colic has been applied. To those cases in which mild attacks of dull pain occur the term "chronic appendicitis" seems best fitted. Digestive disturbances, mu- cous stools, flatulency, and alternating constipation and diarrhea are often associated with the pain. On palpation a somewhat tender, elongated mass can often be felt in the appendix region, and the patient will usually refer the pain to this point. There is no accompanying rise of temperature or leukocytosis. If adhesions exist between the adja- cent coils of intestine, there are indefinite colicky pains which radiate from the ileocecal region toward the rest of the abdomen. In palpating these cases to confirm the diagnosis, one will often feel a cylindrical mass in the right ihac region, which feels like a chronically inflamed appendix. This mass can be followed upward and downward much further than an appendix, and a similar mass is always to be felt in the left iliac region. CHRONIC INTESTINAL OBSTRUCTION. 341 These cylindrical tumors are the markedly contracted cecum and as- cending colon on the right, and the descending colon on the left side, respectively. The condition is often to be found in thin individuals, especially in neurasthenics who suffer from a chronic mucous colitis, so frequently accompanying a chronic appendicitis. The differentiation of these chronic appendicitis cases, in women, must be made from chronic inflammatory conditions of the adnexa, and this usually can be done by careful bimanual examination ; if necessary under an anesthetic. In addition, the pain of appendicitis is, as a rule, higher up than that arising from the adnexa. If much inflammatory exudation has occurred, it may be impossible to differentiate these two conditions, and they often coexist. From gallstones these cases of chronic appendicitis can generally be distinguished by the fact that the tenderness in gallstones is just beneath the costal arch unless a Riedel lobe or hepatoptosis is present (Figs. 162, 183). In appendicitis the tenderness and tumor are in the right ihac region, at McBumey's point, or along the lower half of the right border of the risrht rectus. CHRONIC INTESTINAL OBSTRUCTION (ENTEROSTENOSIS). Total occlusion of the intestine means a complete obstruction to the passage of feces, either through paralysis of the muscular fibers or owing to mechanical causes. The former, or paralytic ileus, is most often due to septic peritonitis, but may at times result from non-septic (neuro- pathic) causes. The diagnosis of this neuropathic or paralytic form of intestinal ob- struction can rarely be made if due to non-pyogenic causes. If caused by septic infection, the chnical picture is that of an acute peritonitis. The latter has been discussed in connection with its most frecjuent cause. Intestinal obstruction as an acute process is taken up in connection with the other acute abdominal affections, since the diagnosis of its exis- tence must be made in connection with that of these conditions, in the majority of cases. By chronic obstruction of the intestine (enlerostenosis) is meant a chronic incomplete interference with the passage of feces. If, as not in- frequently occurs, the occlusion of the lumen becomes complete, the clinical picture changes to that of acute intestinal obstruction (see page 277). The only exception to the above statement is in those cases of strangu- lated hernia in which only a portion of the wall has been caught in the 342 THE ABDOMEX. hernial opening (acute partial enteroceles) . Although the lumen is not completely occluded from an anatomic point of view, yet the symptoms are the same as those in which the obstruction is complete and acute in its course. Diagnosis. — The diagnosis of intestinal stenosis is made from a study of the histon.^, the symptoms, and the physical examination, which conform closely to the following: 1. Constipation. — This is often the first s}Tiiptom and may exist for a long time alone. The patient begins to notice that a movement of the' bowels is difficult without a purgative. Xot infrequently the constipa- tion alternates with attacks of diarrhea. Constipation is an early symp- tom in stenosis of the large but a ven,' late one of the small intestine. 2. Colic. — Often this is the earliest s}Tnptom directing attention to the possibihty of a stenosis. The attacks of pain may be quite severe or ver}^ mild. The pain is oftenest localized at the seat of the stenosis, but may be quite difl'use. These paroxysms of pain are often accompanied by vomiting. 3. Visible Peristalsis. — When A'igorous peristaltic waves can be seen passing across the abdomen accompanying colicky pains, the diagnosis of enterostenosis is easily made. The loops above the stric- ture remain distended but a short time and can often be grasped by the hands of the examiner. 4. Tympanites. — The degree of abdominal distention varies accord- ing to the completeness of the stenosis. It may become so marked as to cause considerable dyspnea. Unsuccessful eft'orts to pass flatus when the abdomen is more or less distended should direct the attention of a physician toward the possibihty of an enterostenosis. 5. Condition of Feces. — The presence of obstinate constipation, al- ternating at times with diarrhea, has already been mentioned. If the obstruction is low down, diarrhea may be almost constantly present. Blood and pus in the feces are often found, but are not pathognomonic of an enterostenosis. If ribbon-hke bands of fecal matter are constantly passed they are of great value in making a diagnosis. 6. The examination 0} the abdomen for a palpable or visible tumor, and bimanual examination of, the rectum and pelvis in general in both sexes, should be a matter of routine in every case. In high-seated rectal strictures due to carcinomata, proctoscopy is often the only means of making an early diagnosis (see page 358J. 7. The history of the case may throw some light on the probable seat and nature of the process. Progressive loss in weight accompanied by symptoms of enterostenosis speak for malignancy (page 341). TUBERCULOUS PERITOXITIS. 34- 8. One should inquire carefully for a histor}-of syphilis, of tuberculosis, of pre\'ious typhoid, of dysenter}', or of operations involving the various abdominal viscera, including the rectum. In regard to the diagnosis of the seat of the stenosis, the locahzation of the pain and of the peristalsis may be of aid, in addition to the facts learned from abdominal and pelvic examination. TUBERCULOUS PERITONITIS. In general, it may be said that tuberculous peritonitis occurs in five forms. 1. As part of a general mihary tuberculosis. As a rule, these cannot be diagnosed dur- ing Hfe. 2. As a latent disease whose presence is only dis- covered accidentally at an operation for other condi- tions. 3. An acute form with tenderness, rigidity, fever, etc., or as a slower form resembUng typhoid. Both of these have been de- scribed in the section on acute abdominal affections ^ ' ^ (page 250). 4. Those in which there is either an encapsulated exudate, or the formation of a firm mass resembling an abdominal tumor. These have been consid- ered in the section on abdominal tumors (page 307), but will be enumer- ated again : (a) Tumors due to rolling up, also called ''puckering of the omen- tum." (b) Encapsulated exudates (Figs. 195, 196). (c) Tumors due to retraction, thickening, and adhesion of adjacent coils of intestine (Tigs. 195, 197). (d) Tumors due to enlarged mesenteric glands in children. Fig. 206. — Area of Dullness in Extensive Encapsulated Tuberculous Peritonitis. 344 THE ABDOMEN. 5 . The ascitic form of tuberculous peritonitis. The last named cases present the clinical picture of free fluid in the peritoneal cavity. In this variety the amount of fluid is usually not as great as in ascites due to cirrhosis of the liver and there is a great ten- dency to early encapsulation. If a pleurisy or other evidences of tuber- culosis exist, the diagnosis is easy, as in the case shown in Figs. 206 and 207. There is often a previous cervical lymph-node infection, or a suspicious family history. In addition to the ascites, there is always more or less tympanites, so that the disten- tion of the abdomen is greater than the amount of fluid, as evidenced by the dullness, would lead one to assume. There is often but httle, if any, fever in the ascitic forms. There is usually more or less emaciation, although there are many exceptions. The pres- ence of an encapsulated exu- date, in addition to the free fluid, is quite diagnostic of tu- berculous peritonitis. The use of tuberculin may clear up the diagnosis in doubtful cases, but it should be employed rarely. Differential Diagnosis of the Ascitic Form. — Ascites Due to Cirrhosis oj the Liver. — An alcoholic history and the presence of a splenic tumor, as well as the more marked enlargement of the superficial veins, speak for cirrhosis. The ascitic fluid in cirrhosis is clear, watery, with low specific gravity, and contains only a trace of albumin, while in tuberculosis it contains more albumin and is often flocculcnt. The presence of encapsulated exudate also speaks for tuberculosis as well as slight evening rise of temperature. The inoculation of guinea-pigs with positive results or the use of tuberculin makes the diagnosis absolute. Carcinomatous Afjections Involving the Peritoneum. — In this con- FiG. 207. — Lateral View of Abdomen in a Case of Tuberculous Peritonitis. Same case as shown in Fig. 206. Note the promin- ence of the lower half of the abdomen corresponding to the area of dullness shown in Fig. 206. Also observe the emaciation. Fig. 208. — Section of a Coil of the Ileum from Case Shown in Fig; 206 Illus- trating THE Pathology of Tubercular Peritonitis. Note the yellowish raised miliary tubercles between which the intestine is markedly hyperemic. The veiled appearance of the upper half is due to the fact that in this portion the pseudo-membrane has not been stripped off from the underlying tubercles. This membrane is shown in a wrinkled or rolled up manner at about the middle of the picture. METHODS OF EXAMINATION. 345 dition the fluid is often hemorrhagic. Emaciation is much more rapid, and after the fluid has been evacuated tumor masses can be felt, which are harder and more nodular than those due to any tuberculous process. The Rectum, methods of examination. The methods generally employed are: (a) Inspection; (b) Palpa- tion; (c) Use of Specula. (a) Inspection. — The best position for examination of the anus and lower portion of the rectum is in one of three positions. Where one is not provided with assistance, as in ordinary office work, the genupec- toral position is in general the best. For hospital work, or where one has an assistant, the examination is best conducted wath the patient in the lithotomy or in Sims' fsemiprone) position. For the examination of the upper portion of the rectum the extreme knee-chest (genupectoral) pos- ture is most suitable. (b) Palpation. — This should never be omitted as a portion of the routine of diagnosis of abdominal conditions, and especially where symp- toms pointing to rectal disease are complained of. The examination is best conducted in either the recumbent, or knee-chest position, the well oiled index-finger being used. A box of rubber finger-cots or some heavy rubber gloves for this purpose should be a part of the armamentarium of every physician, since one can palpate almost as well through these as with the unprotected finger. (c) Use of Specula. — There are many different kinds of rectal spec- ula in use, but a solid bivalve speculum which tapers and opens one side is the best. The examination will be greatly aided by the use of either an electric head-lamp or of a head-mirror with reflected light. For the examination of the upper portion of the rectum the use of a proctoscope is indispensable. A speculum should always be well oiled before being introduced and be slightly warm. The bivalve specula must never be rotated after being introduced, but preferably introduced a second time if it is de- sirable to examine a different portion of the rectum. For the demonstration of affections of the lower half of the rectum when the patient is anesthetized, the Sims or Simon vaginal specula are very valuable. The use of other instruments may be necessary in mak- ing a diagnosis of special affections, such as that of probes in anal fistula or of graduated bougies to determine the caliber of strictures. The latter are best passed with the aid of the proctoscope. 346 THE ABDOMEN. History. — Before beginning the examination every patient's history- should be taken as accurately as possible, as follows : 1. Pain. — What is its character? Is it sharp, lancinating, burning, throbbing, or only a sensation of pressure ? Relation to bowel movements ? Is the pain intermittent ? is it in- dependent of the movements? does it precede, accompany, or follow them ? How long does the pain last ? Is it felt in the rectum or around it, or does it radiate ? 2. Bowel Movements. — Does constipation or diarrhea exist? Is the stool formed or loose ? is it ribbon-hke ? is the odor marked ? 3. Escape of Blood, Pus, etc. — Does mucus, pus, or bloody discharge exist ? How often does this occur, in what quantity, and does it accom- pany defecation or occur independently ? Is the blood black and tarry, is it fresh and red, or are the feces merely streaked with blood ? 4. General Condition. — ^ Whether any organic disease of the heart, liver, or kidneys exists ? Has the patient a family or personal history of carcinoma, tuberculosis, syphihs, or gonorrhea? Does any other pelvic condition exist? 5. Character of Protrusion, if Any. — Does it bleed ? Can it be readily reduced ? Does it protrude during defecation, or at regular periods ? CONGENITAL MALFORMATIONS. There are four chief forms of this condition : (a) Atresia Ani (No. i of Fig. 209). — The anus is entirely absent or only represented by a slight depression. The bowel ends blindly and may be separated from the skin by a thin membrane. This is the most frequent form. (b) Atresia Ani et Recti (No. 2 of Fig. 209).— The anus and rectum are not developed. The colon ends as a blind sac at the level of the sacral promontory. There is no indication externally of an anus. (c) Atresia Recti (No. 3 of Fig. 209). — The rectum is formed down to the level of the sphincters. The anal portion is normally formed. Both, however, end blindly and may be separated only by a membrane or by a septum of connective. tissue which is i to i^ inches (3 to 4 cm.) thick. (d) Abnormal Opening of the Rectum (No. 4 of Fig. 209). — The anus is closed and the rectum opens into either the vagina or into the bladder, or even into the urethra. The diagnosis of which one of these four conditions is present, can seldom be made before operation. As a result of retention of meconium INJURIES OF THE RECTUM. 347 the abdomen becomes greatly distended and vomiting follows. The lat- ter may be feculent at an early period or only appear late, if a peritonitis has begun. In every new-bom child which does not pass meconium within six to twenty-four hours after birth, the anus should be examined. A number of these cases have been operated upon successfully in which such an early diagnosis was made. Fig. 2og. — Various Forms of Congenital Malformations of Anus. (See page 346.) B Bladder; R, rectum; A, primitive anus. In figure 4 the white arrow shows the communication between the bladder and rectum (Esmarch). INJURIES OF THE RECTUM. These may be divided into ruptures and penetrating wounds. In the former class belong {a) those which accompany a fracture of the pelvis, {h) those following violent straining during defecation. This is more apt to occur in women who have previously had a rectoccle. (c) Extension into the rectum of perineal lacerations during parturition. Penetrating wounds follow stab or bullet wounds, falls upon a picket fence or other sharp object, careless introduction of enema points or of bougies. 348 THE ABDOMEN. In the diagnosis of an injury to the rectum the important points are the histor}', the accompanying internal or external signs of injur}-, and the escape of blood or of intestinal coils through the anus or vagina. Later on there are the signs of infection with the formation of an ischiorectal abscess or of a more diffuse perirectal phlegmon. If the tear passes through the peritoneal attachment the signs of a septic peritonitis appear within a few hours after tlie injury. The hemorrhage from a wound or tear of the rectum may be a con- cealed one, the blood accumulating in the rectum and pelvic colon while the patient shows signs of internal hemorrhage, such as pallor, s}mcope, rapid empty pulse, restlessness, etc. In addition to the above mentioned symptoms, a digital examination and the use of a speculum are necessary to confirm the diagnosis. FOREIGN BODIES IN THE RECTUM. These may be divided into three classes : (a) Those which have formed within the body, e. g., gallstones, enteroHths, impacted feces. The last named may attain the size of a child's head. (b) Those which have been swallowed, e. g., fish-bones, peach-stones, rings, all sorts of objects swallowed by the insane, such as forks, spoons, nails, balls of hair, etc. (c) Those which are introduced through the anus, either accidentally or with some object in view, such as aiding a bowel movement or in the insane, or in sexual perverts. The diagnosis may be made in many of the cases if attention has been directed to the rectum through one of the following symptoms : (a) The occurrence of tenesmus accompanied by the passage of blood or mucus in elderly people, who have suffered from obstinate con- stipation. In others the first signs may be inability to urinate through pressure on the urethra. (b) The occurrence of evidences of an infection of the perirectal tissues. (c) The history of swallowing some foreign body or its introduction through the anus. One should never neglect under the above conditions to make a thor- ough digital examination and to combine with it, the use of the speculum. INFLAMMATORY PROCESSES AXD THEIR RESULTS. 549 INFLAMMATORY PROCESSES AND THEIR RESULTS. These include : (a) Pruritus ani, (b) proctitis, (c) perirectal infection (phlegmons and ischiorectal abscesses), (d) fistulas, (e) ulcerations, in- cluding anal fissure. Pruritus Ani. — This is often associated with chronic constipation, hemorrhoids, etc., and in some cases, no cause can be found. It causes an intense itching, especially at night. The skin of the anal region becomes of a silvery white color and is greatly thickened. The disease often appears periodically with each menstruation or pregnancy. Proctitis. — This occurs in an acute and chronic form. In acute proctitis there is (a) pain in the rectum radi- ating to the coccyx, peri- neum, or thighs, (b) Con- stant straining and the pass- age of mucus and blood. There is intense pruritus ani. (c) Constant desire to urinate. There may be re- tention of urine, (d) Both external and internal sphincters are found mark- edly contracted when the finger is introduced. The rectum feels hot and is very tender, and if a speculum can be introduced the mucosa is seen to be greatly congested and swollen. Chronic Proctitis. — The most common causes in children are the presence of polypi or of pin- worms; rarely it is due to a congenital syphihs. In adults it either follows an acute attack or is chronic from the beginning, and then is most frequently due to syphilis or gonorrhea, less often to tuberculosis or a prolapse. There are two forms, a hypertrophic, in which ulcerations and papil- lomatous excrescences occur on the mucosa, and an atro])hic or stenosing form. The two may be combined in some cases. In the latter, which is most often due to syphihs, there is either circumscribed or more diffuse Fig. 2IO. — ^Larked Elephantiasis of the External Fe- male Genitalia and Syphilitic Condylomata of RECTUil. I, Elephantiasis of the clitoris; 2, elephantiasis of left labium majus: 3, similar condition of right labium minus; 4, syphiUtic condylomata of rectum. 350 THE ABDOMEN. infiltration of the entire thickness of the rectal wall and of the perirectal tissues, resulting in the formation of strictures (see page 357). The diagnosis of the hypertrophic form may be made if there is a" history of a preceding acute attack followed by frequent bowel move- ments, consisting principally of pus and mucus. This condition may alternate with constipation. In some cases there is but little tenesmus or pain, while in others it is very marked. Perirectal abscesses and fistulas very often complicate the cHnical picture, especially if the pus cannot readily escape through the anus. There is in many cases the history of a gonorrhea or the presence of fissures, hemorrhoids, or fistula. Examination with the finger or specu- lum, and in some cases through the proctoscope, will confirm the diag- nosis in the hypertrophic form. From carcinoma, the hypertrophic form can be differentiated by the fact that there is soft mucosa between the individual polypoid elevations. There is also an absence of the marked induration of cancer. In many doubtful cases a microscopic examination should be made. Multiple polypi in children and young adults may resemble it, but these are usually larger and there is no ulceration between them. In some cases, if ulcerations exist, it is impossible to make a distinction. Perirectal Infection. Diffuse Perirectal Phlegmon. — This may follow insufficient drainage of an ischiorectal abscess or arise through extension of sup- puration from neighboring structures like the prostate or uterus. ]Most frequently it follows some operation upon the rectum in which infection has occurred. The diagnosis can be made from the local signs of infection in the tissues around the anus and those of a general infection. These are marked infiltration, redness, pain, and rise of local and general tem- perature. In a case recently seen the most marked symptom was a retention of urine through pressure on the urethra. The infiltration may extend over the perineum toward the scrotum and resemble an extravasation of urine, but in the latter there is more involvement of the scrotum, while in perirectal phlegmon the chief external swelHng is around the anus. Unless the condition is reheved the septic infiltration spreads and signs of severe general intoxication appear. Circumscribed Suppuration. — This occurs in other locations than the ischiorectal fossa, and it is often of importance to recognize the exact location of a focus. INFLAMMATORY PROCESSES AND THEIR RESULTS. OD These may be divided (Fig. 211) into: I. Intrasphincteric abscesses, i. e., inside of the sphincter ani. (a) Subcutaneous. Fig. 211. — Various Forms of Ischiorectal Abscesses and Fistul^e. Fig. I, Locations of ischiorectal abscesses: IR, Ischiorectal fossa; £, external sphincter; 5, internal sphincter; B, ramus of ischium; U, space above levator ani muscle; JV, mucous membrane of rectum. The same figures apply to the lower illustration, i, Most frequent form of ischiorectal abscess, pushing skin of anal region outward; 2, submucous abscess above the internal sphincter; 3, abscess situated above levator ani muscle in pehdc connective tissue; 4, subcutaneous extrasphincteric abscess. Fig. 2, On the left-hand side is seen a complete internal and external fistula. On the right side is seen a fistula situated beneath the mucous membrane and burrowing deeply into the upper portion of the ischiorectal fossa. IE of this lower illustration represents an incomplete fistula, having only an external opening. (b) Submucous. (c) Both of above combined. 2. Extrasphincteric abscesses (ischiorectal). 3. Abscesses of the superior pelvirectal space (deep-seated). 352 THE ABDOMEN. Diagnosis of Intrasphincteric Abscesses. ^ — The first sign is usu- ally pain referred to the anus, accompanied by tenderness on pressure. Examination with the finger will reveal in the first variety (subcuta- neous) an area of quite circumscribed tender induration just beneath the skin and close to the anal margin. In the submucous variety the finger must be inserted through the anus. One then feels a boggy,, tender swelling just above the anal margin beneath the mucosa. When these two are combined (submucocutaneous) the external indurated area passes directly over into the one situated within the anal margin. The local symptoms are accompanied by fever, constipation, malaise, etc. In many cases the abscesses have already ruptured spontaneously when the patient is examined. One will then find an external fistulous opening which does not lead alongside the rectum, as do the true anal fistulae. In case a submucous abscess has burst, the opening will be found just above the external sphincter and the cavity lies beneath the mucosa quite superficially. Extrasphincteric Abscesses. — These are the varieties ordinarily spoken of as ischiorectal. They may follow any of the intrasphincteric forms or arise in the deeper parts of the ischiorectal fossa. If the infection begins near the skin, the symptoms of suppuration are more marked than if it begins deeply. There is pain referred to the ischiorectal region in the superficial form, accompanied by tenderness on pressure. The skin over the ischiorectal region becomes red, edematous, and hot, and there are soon evidences of fluctuation. Frequently the abscess breaks spontaneously. In the deeper variety the symptoms are often quite obscure at first. There is deep-seated pain accompanied by signs of general infection, such as high fever, prostration, rapid pulse, etc. If the finger is pressed upon the ischiorectal region either from with- out or through the rectal wall, there is considerable tenderness. The signs of infiltration of the skin of the ischiorectal region appear at a later period. If the pus is not evacuated an abscess of the upper pelvirectal space may result, or the pus may travel around the rectum to the opposite ischiorectal region. The abscess may open spontaneously at some dis- tance from the anal margin. Abscesses of the Superior Rectal Space (Fig. 211). — These may result from suppuration in the prostate, in the periuterine tissue, in the rectum and bones of the pelvis. Abscesses of this space may also be INFLAMMATORY PROCESSES AND THEIR RESULTS. 353 the result of neglected ischiorectal abscesses, or, on the other hand, abscesses of this space can perforate into the ischiorectal fossa (Fig. 211). The diagnosis of these abscesses is often very difficult. There is deep-seated pain, fever, and signs of general septic intoxication. Locally there is, in addition to the pain, often retention of urine, constipation, and infiltration of the tissues around the rectum. Through rectal or vaginal palpation one can distinguish the point of greatest tenderness. The differentiation of this variety from abscesses of the prostate, pelvic abscess, or bone suppuration is often very difficult, and at times impos- sible, except from the history and the fact that the tenderness and in- duration in this form are most marked in close proximity to the rectum. Fistula in And. The majority of these follow an infection of the perirectal tissues with abscess formation, whether due to the ordinary pus organism or the tubercle bacillus. The common varieties are sho\\Ti in Fig. 211. They are: 1. Complete. The external opening is located either close to the anus or at some distance away in the gluteal or perineal regions. The internal opening is usually posteriorly, at the junction of the two sphinc- ters, seldomi above it. 2. Incomplete internal. There is only an inner opening leading into a blind sinus. These are infrequent. 3. Incomplete external. The sinus in the majority of cases lies just beneath the skin, and it is formed from one of the intrasphincteric variety of abscesses described on page 352. There are, however, a number of these which are the result of a complete fistula in which the inner opening has closed. The rarer varieties of fistulae are : (a) Complete internal (both openings internal). (h) Complete external (both openings external to the rectum). (c) Rectovaginal and rectovesical. (d) Horseshoe. (The sinus runs around the rectum like a horse- shoe. There are often many -external openings and branch sinuses running in all directions.) The diagnosis of a fistula is not difficult if an external opening exists from which pus is discharged. This may cease for a time but reopen again. The incomplete internal fistulcC cause some pain on defecation and the discharge of pus. In order to demonstrate the course of a fistula a flexible probe should 23 354 THE ABDOMEN. be used, aided by the finger inserted into the rectum. One should never use any force in passing a probe along the tract. In the majority of fistulae the inner opening is located posteriorly, about half an inch above the anus, and can be felt as a depression, or more often a slight elevation. The opening may in rare instances be at any point. At times the injection of methylene-blue into the external opening or the injection of bismuth followed by the taking of an x-ray picture (Beck) will aid in finding the inner one. The presence of openings on both sides of the anus indicates a horse- shoe fistula. In incomplete internal fistula one feels an induration on inserting the finger into the rectum and a depression where the fistulous opening is located. For the diagnosis of these, the use of a speculum is usually necessary. Tuberculous fistulae usually accompany the same disease elsewhere, and the external opening is large, hned by pale, flabby granu- lations, and the edges are bluish and often undermined. Non-tuber- culous fistulae may, however, exist in phthisical patients. Anal Fissure. The most prominent symptom of this condition is pain of a severe character on defecation. On account of this pain there is marked con- stipation. The other symptoms are intense pruritus and reflex distur- bances, such as increased desire to urinate. The diagnosis can be made from the severity of the pain on defecation and from the local examination. The latter will often show an acute inflamed external hemorrhoid, the " sentinel pile," on the inner side of which the painful ulcer or fissure can be seen. In some cases digital examination is necessary. The sphincter will be found tightly contracted and the finger or probe can be made to touch every point until the painful spot is found. The latter is slit-like and has somewhat hard edges. Non-malignant Ulceration. These may be (a) traumatic, (b) catarrhal, following acute or chronic proctitis, (c) dysenteric, (d) gonorrheal, (e) tuberculous, (/) syphilitic, (g) varicose. The chief symptoms of all of these are the same as those of a chronic proctitis, viz., the discharge of pus and blood accompanied by diarrhea. The evacuations are usually accompanied by tenesmus and hemorrhage in a greater or less degree. The diagnosis can be made (a) by taking an accurate history; (b) HEMORRHOIDS. 355 by a careful examination of the rest of the body for evidences of syphihs, tuberculosis, etc.; (c) by a local examination. In almost all varieties there is marked contraction of the sphincter. In syphilis ulceration is most frequent in the tertiary stage, and especially marked in the lower part of the rectum. The same is true for gonorrhea. Both cause marked infiltration of the rectal walls and multiple ulcerations. Tuberculous ulcers have an irregular shape, are of large size, have undermined edges, and the base is not indurated. It is most frequent around the anal margin or close to the external sphincter and is often accompanied by a fistula. In some cases of rectal ulceration an exact diagnosis of its nature is very difficult, if not impossible. HEMORRHOIDS. These are usually divided into : (a) External (covered by skin). (b) Internal (covered by mucous membrane). (c) Combination piles (a and b combined). It is important from a diagnostic point of view to distinguish : (a) Those which are secondary to pregnancy, diseases of the heart or liver, uterus and adnexa, or to tumors of the rectum or prostate. (b) Those which are primary. The diagnosis of hemorrhoids can be readily made in the majority of cases. In the uncomplicated cases the patients complain of a feeling of weight, of an itching or burning sensation and occasional tenes- mus. There is but little pain unless an ulcer or a fissure coexists. If internal hemorrhoids prolapse there is some pain until they are returned. In many cases the patient's attention is first directed to the rectum on account of frequent bleeding. The latter may be quite profuse or be small in amount and occur with every bowel movement, so that the patient becomes quite weak and anemic. External hemorrhoids are usually visible upon simply exposing the anal region. Internal hemorrhoids are seldom to be seen unless the patient strains or they protrude during defecation or they have become inflamed. External hemorrhoids are either soft, fleshy, bluish masses, or firm skin tags which cannot be reduced. If of the softer variety they can be caused to disappear by pressure, but the mass rapidly reappears. In- ternal hemorrhoids are covered with dark red, swollen membrane. 356 THE ABDOMEN. They may be single or multiple, the latter forming a fringe around the anal margin when they are protruded. Allingham distinguishes three kinds of the internal variety — capil- lary, venous, and arterial. The first named are deep red, bleed readily and profusely. The venous are quite large, firm, of a pale hvid color, do not bleed much, and readily protrude. The arterial are firm, large, bleed readily, and the blood spurts as from an artery. Of these, the capillary and arterial are rare, the venous being the common variety. The complications of hemorrhoids are thrombosis, inflammation, strangulation, and sloughing. Thrombosis usually occurs in the external variety. The hemor- rhoid becomes very hard and greatly enlarged. It causes the patient great discomfort and frequent attacks of tenesmus. Inflammation most often complicates the internal variety. The hemorrhoids become very painful and firm and remain protruded. Sloughing and strangulation are rare complications. PROLAPSE. This condition of protrusion of the rectum is quite frequent in chil- dren and in old people, but may occur at any age. It is more frequent in women than in men, associated in the former with general enteroptosis and uterine prolapse. The most common form is a prolapse of the mucous membrane only. This is called a partial prolapse and usually occurs in children. A complete prolapse of all the coats (Fig. 212) occurs less fre- quently than the partial form. It is the usual form in adults. The diagnosis of prolapse is easy. The protrusion embraces the entire circumference of the bowel and is of reddish color with a depression in the center. The partial prolapse of children can be readily reduced and protrudes only when the child strains as at a stool, etc. The com- plete prolapse remains out most of the time and the mucous membrane becomes very sensitive and bleeds easily. The condition can be dis- tinguished from hemorrhoids. by the fact that in the latter the protrusion is irregular and one can feel the separate, soft, dark blue, hemorrhoidal tumors. Epithelioma of the anus feels quite hard and cannot be reduced. The surface is often ulcerated or covered with cauhflower excrescences. An intussusception, when it protrudes, may resemble a prolapse. The finger when passed around the edge of the protrusion will find a groove or sulcus between the skin and the mass, while in prolapse this is absent. STRICTURES OF THE RECTUM. 357 STRICTURES OF THE RECTUM. These may be divided into annular and tubular, according to whether the stenosis is circumscribed or more diffuse. For diagnostic purposes a good division is into : I. Extrinsic, caused by pressure from without, as from cancer of the prostate or rectum or from pelvic exudates, or tumors of the bones of the pelvis. iitni Fig. 212. — CoMPLETK Prolapse of the Rectum. L, Depression corresponding to lumen of rectum; PM, prolapsed mucous membrane of rectum. 2. Intrinsic, due most often either to (a) syphihs, (b) carcinoma, or (c) gonorrhea. Congenital, traumatic, dysenteric, and tuberculous strictures are very rare in their occurrence and their existence is denied by many experienced proctologists. The diagnosis of the existence of a stricture is not difficult from a consideration of the symptoms and local iindings. As to the etiology of any particular case, the question is a more difficult one. The most prominent symptom is constipation, which may increase to complete stenosis, followed by symptoms of intestinal obstruction. In some cases the first symptom is a persistent diarrhea, accompanied by marked 358 THE ABDOMEN. tenesmus. In the non-malignant cases there is a frequent discharge of pus and mucus. Pain is not a prominent symptom, but in the mahgnant cases there may be marked radiation of pain along the sciatic nerves. The local examination should be made first with the finger; then, if it is necessary, the speculum or proctoscope may be used. The syste- matic use of the latter is to be warmly recommended where symptoms of stenosis exist. It should be combined with the examination of the lower rectum with the finger and speculum. One can make an early diagnosis of a high-seated stricture by this means better than by any other. In making a diagnosis of the cause of the stricture the history is of great value. Syphilis is the cause of the majority of non-malignant strictures, and careful inquiry must be made as to the possibility of an acquired or congenital syphilis. Search should be made for evidence of the disease. Gonorrheal stricture is more frequent in women and can only be diagnosed from the history and the absence of syphilis. Stricture from extrinsic causes can be diagnosed by the examination of the pelvis, the uterus, the prostate, etc. To differentiate a non-malignant from a malignant stricture the following table from Ball will be of aid: DIFFERENTIAL DIAGNOSIS BETWEEN NON-MALIGNANT AND MALIG- NANT STRICTURE.— (Ba//.) Non-malignant Stricture. Mai.ignant Stricture. 1. Generally a disease of adult life. i. Generally a disease of old age. 2. Essentially chronic, and not implicating 2. Progress comparatively rapid and general the system for a long time. cachexia soon produced. 3. The orifice of the stricture feels like a 3. Masses of new growth are to be felt hard ridge in the tissues of the bowel. either as flat plates beneath the Polypoid growths, if present, are mucous membrane and the muscular felt to be attached to the mucous tunic, or as distinct tumors encroach- membrane. ing on the lumen of the bowel. 4. Ulceration of the mucous membrane may 4. Ulceration, when present, is evidently be present, but without any great in- the result of breaking down of the duration of the edges. neoplasm; the edges are much thickened and infiltrated. 5. The entire circumference of the bowel is 5. Generally, one portion of the circum- constricted unless the stricture is val- ference is more obviously involved, vular. 6. Pain, throughout the whole course, in 6. In the advanced stages pain is fre- direct proportion to the fecal ob- quently referred to the sensory dis- struction, and complained of only tribution of some of the branches of during defecation. the sacral plexus, due to direct im- plication of their trunks. 7. Glands not involved. 7. The sacral lymphatic glands can some- times be felt through the rectum to be enlarged and hard. Inguinal glands hard. NEOPLASMS OF THE RECTUM. 359 NEOPLASMS OF THE RECTUM. Polyps. — These are most frequently found in children. They are adenomata, and usually single, with a narrow, long pedicle. Less often they are multiple and sessile. They may exist for years without causing any symptoms. It is only after they begin to bleed or are caught within the anal orifice that they give rise to symptoms. They may be accompanied by the signs of proctitis (page 349). Whenever a child strains at stool, without showing evidences of a prolapse, and passes blood frequently, the examining physician should insert the little finger into the rectum and examine the entire circumfer- FiG. 213. — Non-malignant Papilloma of the Anus (" International Text-Book of Surgery "). ence of mucosa. A polyp can be readily recognized as a soft, cherry-like, very movable tumor attached to the mucosa by a narrow pedicle. When they protrude through the anus, their mobihty and the presence of a pedicle render differentiation from a hemorrhoid easy. The attach- ment of the pedicle may be high up in the rectum or even in the sigmoid. In prolapse the protrusion involves the entire circumference of the anus, has no pedicle, and a distinct tumor cannot be felt. Broad, sessile polyps occurring in older persons have a tendency to become malignant. Carcinoma of the Rectum. — This is predominantly a disease of old age, but may occur between fifteen and thirty. There are two forms — the epithelioma of the anus and the adenocarcinoma of the rectum proper. The latter form is thirty times more frequent than the former. Carcin- 360 THE ABDOMEN. / oma of the rectum proper arises most often in one of two places: (a) In the ampulla, either as a placque-hke or as an annular growth; (b) at the junction of the rectum and pelvic colon (sigmoid). In the second situa- tion the tumor most often occurs in an annular form. The diagnosis of an epithehoma of the anus is not difficult. It is found either as (a) a wart-like, firm tumor with indurated base, involving a variable degree of the circumference of the anal orifice, or as (b) sl crater-hke ulcer with marked indurated edges and base. The age of the patient and the characteristic induration of the growth render a differ- entiation from ordinary soft venereal warts or hemor- rhoids easy. In cancer of the anus there is early in- duration of the inguinal nodes. Carcinoma of the rectum proper is more difficult to recognize. There are no characteristic symptoms for this condition, but its pres- ence must be thought of when patients, above forty, complain of diarrhea ac- companied by the discharge of pus and mucus, a sensa- tion of weight, pain radiat- ing into the thighs and back, and straining at stool. In some cases, obstin- ate constipation alternating with attacks of diarrhea and the occasional passage of blood will be the only symptoms. With both of these clinical pictures there is often a gradual loss in weight and in strength. If the cancer is located high up near the sigmoid there are indefinite symptoms of enterostenosis, cohc-hke pains, etc. (page 309). In women such a tumor has been mistaken at times for an ovarian or uterine tumor, or for a displaced uterus. For carcinomata situated in the am- pulla digital examination will usually suffice. For those which cannot be reached by the finger, the use of the proctoscope cannot be too Fig. 214. — Carcinomatous Ulcer of Posterior Wall of Rectum. Observe the papillomatous condition of the edges and the crater-like excavation of the center of the ulcer. RENAL AND VESICAL LESIONS. 36 1 warmly recommended. Bimanual examination under anesthesia is also of great aid for these high-seated cancers. The growth may be felt as a crater-like ulcer with hard edges and base situated only on one side of the rectal wall, or it forms an annular, band-like constriction which causes the rectum to feel board-like and to become firmly fixed to the surrounding structures. The chief condition from which malignant stricture of the rectum must be distinguished is syphilis. This has been considered on page 358. Renal and Vesical Lesions. the older and the newer methods of diagnosis of renal and vesical lesions. The older methods of diagnosis may be summed up as follows: (i) The clinical picture. (2) The examination of the urine. (3) The objective examination, i. e., palpation, inflation of the colon, etc. The newer methods include: (i) Cystoscopy. (2) Ureteral cathe- terization. (3) Chromocystoscopy. (4) Cryoscopy and (5) thephlorid- zin test. (6) The use of the x-ray, with or without the aid of metallic sounds. (7) Electrical conductivity of the urine. (These newer methods are discussed in the chapter upon Methods of Examination, The Older Methods of Diagnosis. 1. The Clinical Picture. — This is of value only when the signs are unquestionably those of renal or vesical disease. Symptoms which have been given in the sections upon the diagnosis of these lesions are often deceptive. There may be no pain in renal lesions or it may be referred to the opposite, or healthy kidney. Frequency of urination may be present in both renal and vesical lesions. The pain in both of these conditions may be periodic. As Israel has shown, renal colic may be present both in pyelitis and in acute congestion of the kidneys. 2. The Examination of the Urine. — The reaction of the urine is of little value in some cases, because a pyelitis may show an alkaline and a cystitis an acid reaction. In the majority of cases, if blood is present in the urine and is increased by movement, the case is likely to be one of renal colic, whereas a tumor causes spontaneous hemorrhage. This may be reversed (Casper^). Again, a severe hemorrhage may be the first symptom of a tuberculosis, or a hematuria can occur without any visible renal lesion. The diagnosis of where pus comes from as dcter- ' The author is indebted for much valuable informalion to the excellent book of Casper ("Handbuch der Cystoscopie"). 362 THE ABDOMEN. mined by washing out the bladder is also too uncertain. Pus in larger amounts usually means a cystitis, but one cannot draw conclusions from this, since the same may occur in a pyelitis. One cannot make a diagnosis of the location of a lesion, whether it is vesical or renal, from the presence of the various forms of epithehum in the urine. 3. Objective Examination. — Palpation of a renal tumor is of great value, but unfortunately, in many cases of renal calculus, neo- plasms, or tuberculosis, one cannot feel anything, especially if the patient be very stout or very thin. The larger of the kidneys may be the hyper- trophied one. As was stated on page 305, an enlarged gallbladder or spleen may feel hke a kidney. Inflation of the colon should be tried in Fig. 215. — Apparatus to be Employed foe Inflating the Colon for Diagnostic Purposes. The rubber bulb of a PaqueKn cautery is joined by means of a glass tube to an ordinary rubber rectal tube. every case by inserting an ordinary rectal tube into the rectum (Fig. 215) and forcing air through it with the aid of an ordinary bicycle pump or the bulb of a Paquelin cautery. It may, however, be of no value on account of the presence of adhesions or the fact that the colon does not lie in front of the kidney or it may lie over the gallbladder. The lower part of the ureters can often be felt through the vagina. PYELITIS. The various causes of this condition must be recalled in making a diagnosis. They are: I. A cystitis followed by ascending infection of the ureter and renal pelvis. It is most often unilateral. TUBERCULOSIS OF THE KIDNEY, 363 2. As a complication of renal calculi and of renal tuberculosis. Here it is also unilateral unless the respective condition is bilateral. 3. By extension from neighboring foci of suppuration. Here it is usually unilateral. 4. As a primary condition, i. e., a hematogenous infection. As will be seen by a reference to these causes of pyelitis, the diagnosis is rather that of the accompanying condition than of the pyelitis itself, in the majority of cases. Pyelitis may occur in an acute and in a chronic form. Acute pyelitis most often follows ascending infection from the bladder or occurs as a result of hematogenous infection. The diagnosis may be made from the following : 1. Fever. This may be quite irregular and accompanied by recur- ring chills, or it may be moderate. Often the kidneys are not suspected as the cause of persistent fever, especially in children. 2. Local signs. There are marked pain and tenderness over the kidneys in many cases, but in others there are absolutely no localizing signs of inflammation. Cystoscopic examination shows pus coming from one or both ureters. 3. Urine. There is pus present in large quantities. The reaction may or may not be acid. There is but little albumin present unless a nephritis coexists, and there may be many red blood-corpuscles. The urine is usually decreased in amount and there may be reflex anuria. Chronic pyelitis is most frequently a complication of renal calculi, tuberculosis, or tumors, or occurs as a complication of a chronic cystitis. If the latter is the cause, a diagnosis of a chronic pyelitis cannot be made unless attacks of acute pyelonephritis occur from time to time, when its presence may be suspected. In the other affections, the diagnosis is made from the cause of the pyelitis. TUBERCULOSIS OF THE KIDNEY. It is at present a well accepted fact that the majority of cases are due to hematogenous infection, the disease never being primary in the ureter or bladder. Clinically there are three modes of onset : 1 . Those in which the symptoms of cystitis are present which do not yield to the usual treatment. 2. Those in which the symptoms are those of a chronic pyehtis, i. e., pyuria lasting for years in some cases, before a suspicion of tuberculosis is aroused. 564 THE ABDOMEN. 3. Those in which a sudden hematuria is the first symptom. 1. Those with symptoms of cystitis constitute the majority, the patients often being treated for this for a long time. The first and earhest symptom noticed in this class of cases is that there is increased frequency 0} urination, especially at night. Some patients complain of being obliged to urinate immediately, or there is vesical tenesmus and burning at the end of urination and some pain. 2. In the second mode of onset there is a painless pyuria with little or Fig. 216. — Tuberculosis of the Kidney in its Incipient Stage. I, Caseous broken-down foci at apex of the pyramids in the upper pole of the kidney; 2, miliary tubercles in the cortex. no bladder irritabihty, the urine is acid in character and contains tubercle bacilli. 3. In the third class a sudden severe hematuria of brief duration may be the first symptom to direct attention to the kidneys. Symptoms. — In making a diagnosis one must consider the following symptoms : 1. The various modes of onset- as just described, so that, in general, pyuria in adults between twenty and forty, preceded or not by signs of bladder irritability, should lead to further examination. 2. Urinary Changes. — The reaction is acid, there are but few casts, there is a trace of albumin in the filtered specimen, many pus-cells and tubercle bacilli. In some cases the urine may be quite clear at first. Tubercle bacilh can be best found if several pints of urine are used for DIAGNOSIS OF RENAL CALCULI. 365 sedimentation and the sediment stained. If this is unsuccessful a guinea- pig should be inoculated. 3. Pain and Renal Enlargement. — As a rule, there is but little pain. In some cases there is a dull aching in the lumbar region on one side, for years. In a few cases paroxysmal attacks like renal colic occur, but these are rare. In the majority of cases there is palpable enlargement of the affected kidney (nineteen in twenty-four cases observed by Israel), to about twice the normal size. Enormous enlargement is infrequent. The kidney, if palpable, is tender, and in thin women one may also feel the greatly thickened ureter as a hard, tender cord. 4. General Symptoms. — The entire body should be searched for primary foci. Every patient will show a gradual loss in weight and strength and increasing anemia; this is most marked if both organs are involved. There may be either fever of an intermittent type or a differ- ence of one to three degrees between the morning and evening tempera- ture (hectic type) . The injection of tuberculin is justifiable, and is indicated if tubercle bacilli cannot be found. 5. Cystoscopic Examination and Ureteral Catheterization. — The im- provements in this direction have greatly aided in making an early diagnosis of this affection possible and their use should never be neglected. Through the cystoscope one can see ulcerations in the bladder around the ureteral orifices (Kummell). The edges of these are everted, and there is an irregular, dentated, funnel-like ulcer present (golf-hole orifice). When there are ho such vesical changes, only catheterization of the ureters will show the kidney affected, and this can now be done on the suspected side only. DIAGNOSIS OF RENAL CALCULI. In some cases renal calcuH, like gallstones, may be present without causing any symptoms. There are, in general, two classes of cases: 1. Those in which symptoms directly referable to the kidney appear, as renal colic, hematuria, or anuria. "^ 2. Those in which there are no active sym])toms, the so-called quiescent cases. I. Those in which active renal s}'mptoms appear. In the majority of these patients it is the occurrence of one or more attacks of renal colic which attracts the attention of the physician. The 366 THE ABDOMEN. first point to determine in these cases is whether the attack had all of the characteristics of a typical renal colic. The second fact is to ascertain by a process of exclusion, whether the attack of pain, etc., might not be due to other renal or ureteral conditions which produce colic. Renal colic has been discussed on page 270 as an acute abdominal condition. The principal affections from which such an attack must be differentiated have also been referred to These were appendicitis, intestinal obstruction, and gallstones. We must now consider the second question in the diagnosis of active cases, i. e., those producing attacks of renal cohc. This problem is to exclude all other renal conditions which might cause colic. There are three classes of cases which might cause renal colic. These are : (a) Those which produce obstruction of the ureter. These are floating kidney (kink- ing of ureter) , pyonephrosis (plug- ging of ureter by pus), neoplasms (plugging by blood or tumor masses), tuberculosis (plugging by blood or caseous particles). (&) Those which produce cohc with- out obstruction. These are acute congestion, such as occurs in tu- berculosis, acute exacerbations of chronic nephritis, pyehtis, hyper- acidity of the urine, and nephralgia. (c) Colics due to diseases of the ureter, such as ureteritis, strictures, or pressure of tumors from without. The majority of attacks of renal colic are due to calculi, yet it is well to bear all of these other causes in mind in making a diagnosis. The accompanying symptoms of all of the affections mentioned will usually enable one by exclusion to state that the attack was one of renal colic due to calculi. In addition to these renal colics, the diagnosis can be made in these active cases from the same symptoms and objective findings as in the quiescent cases. 2. Diagnosis in the quiescent stage, i. e., when no coHcs are present. These cases occur clinically in two forms. Fig. 217. — artciiiL-N u¥ Calculous Pyelonephri- tis. The specimen shows many calculi in situ both in the cortex and pelvis of kidney. Note the exten- sive destruction of the cortex through the suppur- ative condition following the presence of calculi. DIAGNOSIS OF RENAL CALCULI, 567 (a) Those in which the symptoms are referred to other organs until a cohc or hematuria occurs, e. g., cases treated as floating kidney, cystitis, gallstones, chronic rheumatism, lumbago, intercostal neuralgia, dyspepsia, and uterine or adnexal disease. (b) Those in which there are distinct symptoms referable to the kidneys. The symptoms of both forms may be one or more of the following : Pain. — This is either of a continuous or of an intermittent, dull, aching character, referred to the lumbar region, or there is a sensation of weight or pressure. The pain is very commonly spon- taneous, but is often in- creased by exertion, or the pains may occur at a certain hour. Results of Palpation. ■ — Unless infection has occurred in a calculous kidney, or calculi are combined with a neo- plasm or tuberculosis, no palpable enlargement of the kidney is found. Ac- cording to Israel, such enlargement was found in twenty-two out of thirty cases, due either to sep- tic infection or the result of hpomatous changes. Tenderness of the af- fected kidney will often be complained of on bimanual palpation. This is most marked at the end of a long expiration. The pain is felt either along the ureter or in the bladder or penis, occasionally in the opposite kidney. The ureter is often tender, especially where it crosses the pelvic brim. A shaking of the lumbar region or suddenly extending the thigh after it has been flexed on the body will in some cases cause a sharp pain in the affected kidney. The tension and resistance of the muscles on the affected side is often much more marked than on the opposite one. Urinary Changes. — Careful search of the urine will at some time show 41 W ^ • 4^ Fig. 218. — Renal Calculi after Removal from the Kidney. These are the same as shown in Figs. 217 and 219. Note the variation in size and shape. The round ones, like gallstones of small sizes, can be passed spontaneously, but the irregular ones usually are lodged in one of the calices of the pelvis. 368 THE ABDOMEN. the presence of red corpuscles. These are generally of the shadow variety, i. e., the hemoglobin has been washed out. There is also a trace of albumin in uncomplicated cases. The finding of this combination of washed-out red corpuscles and a trace of albumin is the most characteristic urinary finding, according to Israel, in aseptic cases. If infection of either the pelvis or the kidney has occurred, pus is Fig. 219. — Skiagraph of Rkxai. Calculi taken \mih ihl Aiu ui- a i .jc using Tube. The shadows of the calculi have been outlined in white. XI, Eleventh rib; XII, twelfth rib. found in varying quantities. The presence of crystals of uric acid, etc., is of no value. Hematuria, instead of being microscopic only, may be very profuse and be the first sign of calculus. In such cases a differentiation from tuberculosis, neoplasm, and unilateral or bilateral chronic hemorrhagic nephritis may be very difficult. In calculus the hematuria is, in general, more dependent on exertion, while in tuberculosis and neoplasms this is not the case. Unless infection has occurred, the urine in tuberculosis is likely to contain both red DIAGNOSIS OF RENAL CALCULI. 569 corpuscles and pus, and in the latter there are tubercle bacilli. In nephritis there would be casts and a larger percentage of albumin. It is well to remember that both tuberculosis and tumor may be associated with calculi. The characteristics of the urine in intermittent hydronephrosis have been referred to (page 3^3)- It is always best to col- lect the urine for twenty- four hours in every case of suspected renal calcuh and examine a centrifugated specimen. One must also remember that the passage of uric acid or oxalate of lime crystals may cause red blood- corpuscles to be present in the urine. Disturbances in Micturi- tion. — These may be so marked both as to frequency and urgency, that the case is suspected to be one of cys- titis. In some cases there is pain on urination referred to the side of the bladder cor- responding to the location of the calculus in the kidney. Radiographic Examina- tion. — There can no longer be any doubt that every case of suspected renal or ureteral calculi should be subjected to this method of diagnosis. In- structions as to the preparation of the patient will be found in the special books on this subject. Calcuh differ in the intensity of the shadows which they cause. Oxalate calculi give the sharpest, the urates come next, while phosphatic stones give the least shadow, and pure uric acid scarcely ever gives a shadow. A kidney may contain numerous calculi and yet onlv one or two will 24 Fig. 220. — X-RAY OF a Kidney Removed on Account of Extensive Destruction, due to Calculous Pye- lonephritis. The illustration was made by taking the kidney after it was extirpated and laying it upon an a-ray plate, and then exposing it to the tube, i , Renal calculus which casts an intense shadow; 2, small calculus which tlirows very slight shadow. This is the same kidney as is shown in the x-ray. Fig. 219, and illustrates that many renal calculi do not cast a sufEciently deep shadow to be detected in a skiagraph dur- ing life. The :x--ray shown in Fig. 219 reveals only three shadows, whereas the kidney skiagraph taken after extirpa- tion shows many more calculi. 370 THE ABDOMEN. give a shadow (Fig. 219). Again, we must not overlook the possi- bihty of calcified mesenteric glands or calcareous deposits simulating the calculous shadows. In the case of ureteral stones, where the error is most Hkely to occur, this can be ehminated by taking a picture before and after passing a metal ureteral bougie. At present our standpoint is that with proper apparatus, experience, and not too fat a subject, it is possible to detect both renal and ureteral calculi by this method in the majority of cases. A negative result after repeated exposures excludes the presence of calculi. Examination of the Bladder and Ureters. — In some cases confirmatory evidence of which kidney the hematuria comes from may be obtained by the use of a cystoscope or the use of the Harris segregator or Luys apparatus. Of these, the cystoscope is the most accurate, but requires the greatest experience and dex- terity. If the hematuria is quite marked ureteral catheteriza- tion may be advisable (see page 732). Anuria. — In some cases a sudden cessation of the secre- tion of urine may be the first sign of a calculus. Although such a calculus impacted in the beginning of the ureter may be the most frequent cause of anuria, there are other causes which must be excluded, such as bilateral acute or chronic nephritis, obstruction of both ureters by tumors (uterine carcinoma), operations on one kidney and reflex anuria of the opposite one, or anuria due to kinking of the ureter. The history and accompanying symptoms will usually enable one to make a diagnosis of the cause of the anuria. Fig. 221. — Specimen of Double Ureter Formation. RK, Right kidney; LK, left kidney, i, Right ureter; '2 and 3, represent the separate ureters present upon the left side; 4, rudimentary uterus; s, bladder. THE BLADDER — CONGENITAL MALFORMATIONS. 371 The Bladder, congenital malformations. Ectopia Vesicae or Exstrophy of the Bladder. — The most frequent form is the one in which the entire anterior wall of the bladder and the abdominal wall over it is not present. The posterior wall of the bladder presents itself as a red, easily bleed- ing mass which projects beyond the level of the surrounding skin (Fig. 222). Associated with it are usually found a non-union of the pubic Fig. 222. — View of Ectopia Vesica in Same Patient shown in Fig. 223. U., Congenital hernia; F, prolapsed posterior wall of bladder; £, epispadias. bones, a lack of development and deformity (epispadias) of the penis, and a congenital hernia (Fig. 223). The condition can be readily recognized by the red protrusion above the pubis, from which urine constantly escapes, causing irritation of the surrounding skin. To prove the nature of the protrusion one can lift it up a little and watch the jet of urine escape from the ureteral papillae and pass line catheters or probes into these (Fig. 223). The deformity is more often present in females than in males. 372 THE ABDOilEX. WOUNDS OF THE BLADDER. The diagnosis of these has been described in connection with injuries of the abdominal viscera in general (page 243). INFLAMMATION OF THE BLADDER. Cystitis. — Chnically, the division of cystitis into the acute and chronic forms is the most convenient. Acute Cystitis. — Tlie most important s}Tnptoms from which a diagnosis is made are : I. Painful and Increased Frequency of Urination. — The urine is r H Fig. 223. — EcTOPLA. Vesica Accoirp-AJs-izD by Epispadias and Congexital Right-sided Hernia. E, Epispadias. Posterior wall of the bladder is seen prolapsed through the hiatus in abdominal wall. H, Congenital right-sided inguinal hernia. Two catheters are shown passing into tlie left and right ureters respectively. The orifices of the ureters are situated close to the junction of the lower border of the prolapsed bladder with the abdominal wall. voided at shorter intervals than normal. The patient has the feeling of being obHged to pass the urine immediately after the desire is felt (urgency of micturition;. The pain increases with each urination, and the act itself is followed by marked vesical tenesmus, so that the patient in severe cases has an almost constant desire to urinate. Complete retention may occur, only the overflow being involuntarily voided. INFLAMMATION OF THE BLADDER. 373 2. Sensation of Weight and Tenderness. — This is often quite marked in the hypogastric region and perineum. 3. The Urine. — In the majority of cases the freshly voided urine is acid, but soon becomes neutral or alkaline. The urine is turbid owing to the presence of large amounts of pus-corpuscles. The more alkahne the reaction, the more marked is the ammoniacal odor and the larger the number of triple phosphates and mucus present. 4. General Symptoms. — There is usually a moderate rise of tempera- ture with anorexia and sleeplessness. In some cases the disease is ushered in by a chill followed by a rise of temperature of var}'ing in- tensity and with irregular exacerbations. In diphtheritic cystitis all of the above symptoms are more marked, especially the pain and ammoniacal urine. The fever runs a course Hke a typhoid and there are signs of severe sepsis, such as delirium, sweats, and rapid pulse. Chronic Cystitis. — This arises either from the acute variety or begins as a subacute process which becomes a chronic one. The symptoms mentioned above are all less marked. Pain is but slight and often consists only of a mild burning sensation on urinating. The increased frequency and urgency of micturition are quite marked, especially after exposure to cold or errors in diet. After the urine has been passed there is always some residual urine, since the disease is most common where some obstruction exists, such as prostatic hypertrophy or stricture of the urethra or prolapse in women. In those cases which follow an acute cystitis, this residual urine symptom is seldom present. The frequent desire to urinate is especially marked at night. The urine is often alkaline in reaction, containing much pus, epithe- lial cells, and triple phosphates. The complications of acute cystitis are a gangrene of the bladder wall, causing pyemia and death, or the ulceration which may rarely go on to perforation or peritonitis, or an acute pyelonephritis (page 251). The complications of chronic cystitis are: {a) A pyelitis or pyelonephritis. (&) The formation of abscesses in the bladder wall or of a peri^'csical phlegmon in front of or behind the organ. (c) The perforation of the diverticula which often form in these cases, causing peritonitis or prevesical abscess (page 232). (d) A chronic condition of septic intoxication called urosepsis, from the absorption of toxic products from the decomposing urine. The signs of this are frequently recurring chills followed by profuse 374 THE ABDOMEN. sweats and rise of temperature, vomiting, delirium, and a gradual loss in weight. Differential Diagnosis of Cystitis. — Renal Suppuration. — Al- though there are bladder symptoms, these appear and disappear without any special cause, while the quantity of pus remains constant and is greater than in a cystitis. Posterior Urethritis or Prostatitis. — In both of these conditions, as in acute cystitis, there is increased frequency of and painful micturition. The other differential diagnostic points are given on page 381. TUBERCULOSIS OF THE BLADDER. This condition is secondary to the same affection in the kidneys in both sexes, or in the male may, in addition, be secondary to a primary focus in the testis with resultant ascending infection. A priman." tuber- culosis is very rare. In the majority of cases the disease apparently occurs spontaneously. A hematuria may often be the first sjmiptom, followed by painful and increased frequency of micturition. The blood is passed in large clots and is not intimately mixed with the urine, as it would be in a renal hematuria. In other cases the vesical tuberculosis develops in a latent manner as a complication of a gonorrheal cystitis. The urine in the early stages is acid and there is but little pus; later it is alkaline and there is considerable pus and mucus. Tubercle bacilli may be found in centrifugated specimens if a large quantity of urine is used, or some of the pus can be injected into a guinea-pig. The diagnosis is easy if the above symptoms are found in a person who has a primary focus of tuberculosis elsewhere which can be readily detected. Every pyuria or hematuria occurring in young persons without any apparent cause should lead to the suspicion of a vesical or renal tubercu- losis. Hematuria due to cancer occurs at an older period, while that due to calculi usually ceases when the patient is kept quiet, while rest has no influence on the hematuria of tuberculosis. By the aid of the cystoscope one can detect ulcerations at the orifices of the ureters and the neck of the bladder. The presence of renal symptoms and the escape of pus from the corresponding ureter help to confirm the diagnosis. The crucial test, however, is the discover}- of tubercle bacilh either by staining or the guinea-pig inoculation test. VESICAL CALCULI. 375 VESICAL CALCULI. The characteristic symptoms of stone in the bladder are pain, hemor- rhage, and disturbances of micturition. These are very frequently combined with the symptoms of chronic cystitis, or of hypertrophy of the prostate, so that the cHnical picture becomes a complex one. (a) The pain is felt in the end of the penis, especially toward the end of urination, or the pain may be felt at the neck of the bladder, es- pecially upon exertion or sudden jarring of the body. The pains may radiate to the rectum, testis, or thigh. If the calculus is pointed and becomes fixed in the meatus internus, the pain is often excruciating, and is increased by each vesical contraction. (b) Micturition is seldom normal. There is usually increased fre- quency. If the stone is small the stream is often suddenly interrupted. In some cases there is enuresis, in others retention of urine, especially if the calculus becomes wedged in the internal meatus. Obstinate enuresis and dysuria are often the first signs in children. (c) Condition of urine. This contains pus and mucus, varying ac- cording to the degree of cystitis. Blood in small quantities is often mixed with the urine, especially after any exertion. One specimen may contain blood and the next be perfectly clear. In general, the hematuria is never as marked nor as continuous as in neoplasms or tuberculosis, unless the latter coexist. In children, prolapse of the rectum and straining at stool or in urina- tion, or the presence of hernise, should lead to the suspicion of calcuh. The history of a previous renal colic may be of great value. The diag- nosis of vesical calculus can be confirmed by one or more of the three following methods of examination : (i) The use of a specially constructed sound called the "Thompson stone searcher" or the ordinary metal urethral sounds of varying sizes. The bladder should contain two ounces of fluid in children and four ounces in adults, the organ having been previously irrigated with boric acid solution through a soft-rubber catheter. Some 2 per cent, eucain solution is injected into the deep urethra. If the bladder is very sensi- tive a general anesthetic should be given. If the urine is ammoniacal, the examination should be preceded for a few days to a week, if possible, by daily irrigations and the internal use of urinary antiseptics. The bladder should be systematically explored. The horizontal position with elevation of the pelvis is best suited for these cases. If the prostate is enlarged, a sound with a much larger curve is neces- sary. When the sound strikes a stone, there is a sharp metallic click. 376 THE ABDOMEN. A stone which is hidden in a diverticulum or deeply in the retroprostatic pouch is often found with great difhculty. The former may be suspected if the sound only strikes it in one position and cannot be made to pass around the calculus. (2) Cystoscopic examination. This is an almost infallible method, and is especially valuable in the case of calculi which lie in diverticula, or for foreign bodies in the bladder. Its use may be very difficult if there is much cystitis or marked prostatic h5qDertrophy. (3) Skiagraphic examination. This method has been used consider- ably since the introduction of the x-ray. As in the cases of renal calculi, phosphatic, oxalate, and cystin give deep, while urate and uric acid calculi only cause light shadows. The method is only of value if the result is a positive one. No reliance can be placed upon a negative picture. TUMORS OF THE BLADDER. These are divided chnically into the benign and malignant. The majority of the former are papillomata made up of long pedicles or sessile, warty tumors with a broad base. They may be single or multiple and are most often situated near the trigone, and not in- frequently become malignant in character. Of the malignant, the majority are primary either in the prostate or in one of the neighbor- ing structures (rectum, uterus, etc.). The diagnosis of a vesical neo- plasm may be made from the presence of (a) sudden hematuria which is not renal in origin, accompanied by pain and disturbances of micturition, and (b) the results of the examination of the urine, and of cystoscopic and rectal examination. (a) The hematuria may be the first symptom, as it is of other renal and vesical conditions (calculi and tuberculosis). In tumors it is the first sign of the condition in the majority of cases. If the blood comes from the kidney it is intimately mixed with the urine, has been accom- panied by colic, and there are often worm-like coagula. In hemorrhage from the urethra the liquid or clotted blood precedes the voiding of urine. In bladder hemorrhages the first urine contains but little blood, but the amount is gradually increased until pure blood is evacuated. The hematuria from benign tumors is often intermittent, occurring without any cause, is not increased by exertion, and is bright red. In malignant growths the hemorrhage is more persistent, smaller in amount, and more brownish in color. Frequency and urgency of micturition are generally absent in smaller ENLARGEMENT OF THE PROSTATE. 377 benign and malignant growths. In larger ones there is often great difficulty in micturition and even retention of urine. Pain is generally absent in papillomata and is not marked in the carcinomata until the infiltration is extensive or the bladder becomes infected. It is then not only present during, but also between, urination. The discovery of some of the villi of a papilloma is one of the most positive signs, but this is not often found. In the malignant tumors which are primary in the prostate, rectal examination will show a much harder, stone-like enlargement of the gland than is the case in ordinary hypertrophy. In a recent case the writer was led to suspect a malignant prostate from the palpation of very firm lymph-nodes in both inguinal regions of a cachectic man who had bladder symptoms. Rectal exami- nation revealed, in addition to the hard prostate, a stricture due to the extension of the growth around the rectum. In a recent article on cancer of the prostate, Young ^ calls attention to this stony induration, as well as to a similar condition of the seminal vesicles. Cystoscopic examination is of great value. It is very difficult to examine the bladder in cases of villous tumor, owing to the hemorrhage, but if this latter is not too great, the view obtained confirms the diagnosis. In malignant tumors without marked projection above the level of the bladder wall, the diagnosis with the cystoscope is very difficult, but even in these cases it is often confirmatory, especially in disease of the prostate which has invaded the trigone. Wherever there is any doubt as to the nature of the tumor an explora- tory suprapubic cystostomy is advisable in order that an early diagnosis be made. Affections of the Prostate, enlargement of the prostate. Increased frequency of urination, often first noticed at night, in a man above forty, directs attention to the bladder and prostate. There is not only a desire to urinate more frecjuently, but a feeling that it must be passed immediately. The act requires longer than usual, and the stream lacks the force of a normal individual. Retention of urine may begin gradually, the patient being able to pass less and less. It often begins suddenly after exposure to cold, debauches, or voluntary retention of the urine for a long period. Pain is not a symptom of this condition until a cystitis has begun. ' "Johns Hopkins Hospital Bulletin," October, 1905. 378 THE ABDOMEN. Hematuria may at times be very profuse from the varicose prostatic veins around the neck of the bladder. With the above history one can usually confirm the diagnosis by a systematic objective examination. This should include: 1. Palpation of the prostate through the rectum to determine the extent of the enlargement in this direction, whether one or both of the lateral lobes are involved, and the consistency and nature of the enlarge- ment. A fibrous prostate is but little enlarged and is very firm and fiixed. An adenomatous prostate is larger, softer, and more movable. 2. Combined examination by the use of a metal catheter inserted into the bladder, while the index-iinger is introduced into the rec- tum. In passing the catheter the following points, according to Deaver, favor the diagnosis of enlarged prostate, (a) Undue depression of the shaft is necessary before the catheter enters the bladder, (b) The length of the urethra, i. e., before urine comes, is more than eight inches. (c) The catheter is deviated to one or the other side by the unequal lateral lobes, (d) If an obstruction is encountered at a distance of more than seven inches from the external meatus, showing that the obstruction is not due to strictures which never occur in the prostatic urethra. 3. Determination of the amount of residual urine by allowing the patient to evacuate the bladder and then inserting either a metal or a special prostatic catheter, known as the Mercier, with a short beak, and allowing the residual urine to escape. 4. A thorough examination of both the quantity of urine passed in twenty-four hours and its constituency. 5. By rotating the metal catheter around in the bladder gently, one can gain an idea of whether it is dilated or contracted, and also whether any calculi exist. A contracted bladder accompanies a fibrous, a dilated an adenomatous prostate. 6. The cystoscope is of great confirmatory value if it can be used, although this may be very difiicult. Differential Diagnosis, — Cancer of the Prostate. — The induration of the enlargement as palpated per rectum is more stony and involves the seminal vesicles at an early period in a similar induration. There is often early, sharp, shooting pain along the inner side of the thighs or along the sciatic nerves. It also causes early cachexia, and cystoscopic examinations fail to detect much enlargement toward the bladder unless a previous benign enlargement has existed. The inguinal glands are also of stony hardness and enlarged. Sarcomata are very rare and grow very rapidly. Polyps 0} the Bladder {Fibrous). — These are quite rare and cause URETHRA AND PENIS — CONGENITAL MALFORMATIONS. 379 obstruction symptoms like an enlarged middle lobe. Rectal palpa- tion usually shows an absence of enlargement of the prostate. The frequency of hematuria and a cystoscopic examination will aid in dis- tinguishing it. Tuberculosis of the Prostate. — This may cause enlargement of, and the formation of nodules in, the prostate. The disease is rarely primary. The diagnosis may usually be made from the presence of the same dis- ease in the epididymis and the fact that it generally occurs at an earher age than prostatic hypertrophy. The diagnosis of carcinoma of the prostate has been considered on page 378, while that of tuberculosis of the prostate will be referred to in connection with the sahie disease in the male productive organs (page 379). Inflammations of the prostate are discussed in connection with their most frequent etiologic factor, viz., gonorrhea (page 381). Injuries and Diseases of the Urethra and Penis, congenital malformations. Epispadias and Hypospadias. — Both of these deformities can be readily diagnosed. In epispadias there in an imperfect formation of the upper wall of the urethra (Fig. 222). There are three forms: (a) One in which only the glans penis is involved. This is so rare that only three genuine cases have been described, (b) The groove extends back to the middle of the penis, (c) The most frequent form. This form is usually associated with an ectopia of the bladder and a defect in the pubic symphysis (Fig. 223). The penis and the groove on its upper surface are very short and pass directly over into the bladder defect. Hypo- spadias is much more frequent than epispadias. The deformity is due to a defective formation of the lower wall of'the urethra. There are also three forms : (a) The gap or groove involves only the glans penis (hypo- spadia glandis). (b) The groove extends back as far as the beginning of the scrotum. The urethral orifice is at the latter point. This form is less frequent than the first named and is called the penoscrotal form. The penis is usually curved down and laterally, (c) The scrotum is more or less completely divided into two lateral halves. The urethral opening is in the perineum or in the groove between the divided scrotum (perineoscrotal form). The penis is very short and bent downward and the foreskin, as in the penoscrotal form, shows a wide gap. 38o THE ABDOMEN. CONTUSION AND RUPTURE OF THE URETHRA. This condition usually follows a fall upon some object like a plank or an axle, these coming in direct contact with the perineum. It may also follow a blow or kick in the same region, or the perineum may be torn as a result of a fracture of the pelvis. The urethra at the bulbomembra- nous junction is caught between the unyielding pubic symphysis and the object upon which the patient falls. For this reason the tears are most often located at this point. The probability of a rupture of the urethra must be thought of in every case either of blunt force ap- plied to the perineum, or an injury in which the pelvis is crushed. The cardinal signs from which a diagnosis can usually be made are: 1. The appearance of a hema- toma or of a swelling in the peri- neum. 2. The escape of blood from the meatus either with or independently of urination. If it occurs with the latter, blood escapes before urine begins to flow. 3. There is either retention of or great difficulty in urinating and the act is accompanied by great pain in the perineum and at the end of the penis. The urine contains coagu- lated and fluid blood. 4. Urinary infiltration of the sub- cutaneous tissues, penis, scrotum, and anterior abdominal wall. This causes marked swellings, redness, and tenderness of the corresponding parts, and may be followed by severe septic infection or even gangrene. Such extravasation may occur immediately after the accident or graduafly in the course of a few days. In the milder cases of rupture of the urethra there is but httle bleeding from the meatus, the urine is almost clear, and there is only a slight amount of perineal swelling. The diagnosis of the more severe forms depends upon the observa- tion of the large amount of blood from the meatus, the perineal hematoma, Fig. 224. — Enormous Elephantiasis of the Scrotum, Following Traumatic Rupture OP THE Urethra. This is the front view of the patient shown in Fig. 225. PUS m LOWER PORTION OF MALE GEXITO-URIXARY TRACT. the difficult and painful micturition, and at times the urinary infiltration with accompanying sepsis. Traumatic rupture of the urethra may be fohowed by strictures and perineal fistulee (Fig. 225), whose diagnosis is the same as that of the same conditions when due to gonorrhea (page 381). If a patient giyes the history of a fall followed by difficulty of urination, one must always think of a stricture. When a tear of the urethra coexists with a rupture of the bladder and fracture of the pehds, as in one of my cases, the diag- nosis is very difficult, but can usually be made by a careful study of the physi- I cal findings. LOCALIZATION OF PUS IN THE LOWER PORTION OF THE MALE GENITO- URINARY TRACT (FIG. 234). The question whether pus and detritus, causing the urine to be turbid, origi- nate in the anterior or pos- terior urethra or in the ap- pendages of the lower urin- ary tract can be answered in one of the following ways : The Two-glass Test. — After a patient has held his urine for some considerable time — two to four hours — he is adyised to empty some of the urine into one glass, then to stop and to void the balance of the urine into another glass (Thompson test). In a general way it can then be stated that, if only the first portion is turbid or shows floating shreds or flakes, the pus comes from the anterior urethra alone. If both portions are turbid or contain shreds or flakes, the posterior urethra is necessarily involycd in the inflammatory process. Pus production in acute gonorrhea is usually so profuse that the first and second portions will be rendered turbid even if the affection is located in the anterior urethra only. The reason for this is that the posterior urethra does not permit the accumulation of any considerable amount of secretion in its lumen, x^t the very moment that secretion accumulates. Fig. 225. — Posterior View of Patient Shown in Fig. 224. Suffering from Enormous Elephanti.\sis of Scrotum. F, Opening of perineal fistula, which resulted from traumatic rupture of urethra and stricture subsequent to same. 382 THE ABDOMEN. it flows back into the bladder. In this way the secretion becomes mixed with the urine contained in the bladder. The lirst portion of urine voided flushes out the anterior urethra, carrying off the adherent pathologic products. Unless secretion flows back from the posterior urethra into the bladder, the second portion of urine will appear clear. The conclusion to be dra^^^l from this rather crude test must be subjected to the following criticism : A ver}' thick secretion originating in the anterior urethra may still adhere to the mucousmembrane after the first portion of urine has passed. Thus the second portion may also contain flakes of pus that originate in the anterior urethra. Again, at the time of the test there mav be ven,^ little production of pus in the posterior urethra, so that the second portion of the urine appears clear, although there is still disease in the posterior urethra. The two-glass test is only of ^-alue if it is employed repeatedly and at different visits. The principle of this test can be appHed in a more refined manner in the following way: The test is best made early in the day. After the patient has retained his urine for some considerable time, the an- terior urethra is washed out with sterile water, either by using a soft- rubber catheter whose tip does not reach beyond the spongy portion of the urethra or by applying a A^alentine nozzle without overcoming the re- sistance of the compressor urethras. This flushing is continued until the returning fluid appears to be absolutely clear. Then the urine is voided; all impurities contained in this specimen necessarily come out of the posterior part of the urethra. Another valuable addition to this method is as follows : If it is desir- able to gather information as to the question whether secretion comes from the prostate or the seminal vesicles, the anterior urethra is first flushed out in the manner described above. The patient should then pass half of the contents of his bladder. The index-finger is now in- troduced into the rectum, and the prostate and the seminal vesicles are milked, and the patient then voids the balance of his urine. The flushing Hquid used for the irrigation of the anterior urethra contains the pathologic products of this portion. The first portion of the urine voided contains the products of the posterior urethra. The second portion of the urine voided contains the contents of the prostate and of the seminal vesicles. Pathologic products squeezed out of the seminal vesicles have a characteristic serpentine or twisted shape. In very chronic cases, which show scant secretion, some additional means must be employed in order to find the seat of pathologic products. In order to stimulate secretion for twenty-four hours previously to PUS IN LOWER PORTION OF MALE GENITO-URINARY TRACT. ;iiii;^ executing the test, irritating irrigations of the entire urethra are admin- istered — I to 10,000 bichlorid solution or i to 5,000 silver nitrate solution. At the same time the patient is advised to drink some alcoholic beverage the evening before the examination, such as beer or cham- pagne. The pathologic products from infiltrated portions of the urethra are collected by first introducing an ohve-tipped sound; all the places at which the sound shows some engagement are squeezed out over the olive tip by two fingers massaging the urethra from the outside. The resulting discharge is treated in the manner above described. While it is easy and simple to examine specimens of the discharge micro- scopically as to their structure, the search for gonococci, particularly in chronic cases, not only calls for frequent examinations of numerous specimens, but even then may be negative. In all doubtful cases the culture test for gonococci should be employed. Instrumental Examination. — In all acute inflammatory processes of the urethra instrumental examination is contraindicated. The most convenient instrument for endourethral examination is the elastic bulb- ous bougie, Guyon's "explorateur a boule olivaire" or bougie a boule. The bougie a boule carries on its slender shaft an olive-shaped head which is conical at its digital end and sharply cut off at its proximal end. The olive, of the most frequently used bougies, has a diameter of 18 to 20, French scale; it is well to have a whole set, these bougies ranging in size from 8 to 26. In the normal urethra the bougie passes the anterior part smoothly and without any resistance; at the isthmus the head en- counters a slight obstruction; on passing it the patient becomes sensitive to the touch. In the whole length of the membranous urethra the bougie moves slightly engaged; in the prostate it glides easily until we get to the internal orifice, where we feel a slight interference just before it enters the bladder. In some cases the bougie may also be caught in the sinus pocularis. While passing the prostatic urethra the patient usually has a desire to urinate. The largest diameter of the head of the bougie being at its proximal end, the obstructions of the urethra are felt more distinctly on retracting than when the bougie is introduced. The meatus is often so narrow that we have to cut it for some distance before making an exami- nation. The bulbous urethra is occasionally very wide in the young and often in the old, and catches the end of an inelastic instrument as though it were in a blind pouch. This obstruction may be overcome by stretch- ing the penis. Right behind the bulb is the isthmus, which is usually easy to pass, except in ner^•ous individuals, in whom the membranous urethra is generally hyperemic, and we get reflex spasmodic contrac- 384 THE ABDOMEN. tion of the compressor urethrse. Patience and perhaps a few drops of cocaine solution will overcome this obstruction. Any obstructions in the course of the urethra, except those named above, are patho- logic. In strictures we feel friction and unevenness; it feels as if the bougie jumped over a hard string. If a stricture which is too narrow for the bougie to pass has been found, then fihform bougies are resorted to, starting with the smallest number and gradually increasing to larger ones until the diameter of the stricture is found. ]\Iany strictures are sharply hmited and stand out prominently from the healthy or less infiltrated surrounding mucous membrane of the urethra, and a filiform bougie introduced is just as likely to be caught in a pocket of the mucous membrane as to enter the narrow passage of the stricture somewhere in the middle. It is, therefore, a good plan not to try to pass the stricture with the first bougie introduced; if it catches in a pocket, introduce the second bougie, and so on until either all of the blind pockets are filled out with the bulb of the bougie or until one accidentally enters the stricture. We can use conical or cylindrical metal sounds instead of the bougie, but they will not give as much information as the bougie. In- filtrations due to chronic gonorrhea are detected by having the sound in the urethra and palpating with the hand on the surface. The mem- branous and prostatic urethrse can be palpated through the rectum. From the foregoing, it is clear that the introduction of a bougie into the urethra not only permits us to find out the degree of sensitiveness and smoothness or unevenness of the urethral mucous membrane, but it also gives direct means to determine the length of the urethra. ^Most convenient for this purpose are Kutner's graduated bougies. The diameter of the urethra in its different parts can accurately be measured with the end of the urethromcter. The oldest and most frequently employed is that of Otis. Of newer date is the urethromc- ter of Kollmann; the latter, in addition, can be used as a dilator for short distance. Urethroscopy. — The pathologic changes in a large percentage of cases of chronic gonorrhea consist in widespread infiltrations of slight degree, but nevertheless they may cause serious disturbances. In other cases the pathologic changes are confined to small, inflamed, suppurating conglomerations of glands or crypts of ]Morgagni, which, in spite of their small size, are the carriers of virulent infection and the cause of constant discharge of pus. On the other hand, it is not necessary that they betray their presence by any apparent symptoms. There is no secretion and the urine does not contain any filaments for weeks, months, or even years. PHIMOSIS — PARAPHIMOSIS — BALANITIS. 385 Suddenly the patient is attacked by an acute gonorrhea without having exposed himself to infection. Such cases are not rare in every- day practice. The endourethral examination with the bulbous bougie, the sound, and the urethrometer, while otherwise of great service in making a diagnosis, will give little information in these cases; they re- main, therefore, a mystery to the insufficiently equipped physician, and this is what gives chronic gonorrhea the name of being incurable. We must first make a correct diagnosis before we can successfully treat a disease. The most important instrument with which to make a thorough examination is the urethroscope. PHIMOSIS. This is an abnormal narrowing of the foreskin, so that it cannot be retracted to expose the glans. It is most often a congenital condition, but may be acquired as the result of gonorrheal inflammation or chan- croidal ulceration beneath the prepuce. The chief interest from a diagnostic point of view is in the results of the phimosis. These are: (a) Recurrent attacks of balanitis from ac- cumulation of smegma, (b) Prolapse of the rectum or a hernial pro- trusion as the result of straining, (c) Formation of preputial calculi. (d) It favors the development of an epithelioma through irritation of the secretions. PARAPHIMOSIS. Whenever a tight foreskin has been drawn back over the glans penis and is not allowed to slip forward again, a paraphimosis results. This is due to the formation of a contraction ring in the retracted foreskin which prevents the blood from returning toward the root of the penis, causing marked swelling. The condition can be readily recognized from this swelling, which lies just behind the corona glandis and is separated from the main body of the penis by a deep groove corresponding to the con- traction ring. The longer the paraphimosis lasts, the more swelhng, so that the groove or contraction ring may be entirely hidden. It may be followed by gangrene of the foreskin. BALANITIS. This is the result of an infection of the inner or mucous layer of the prepuce. The entire prepuce is swollen and tender so that it can only be retracted with difficulty. The glans penis and inner layer of the prepuce are both reddened and ulcerated, and a foul purulent discharge 386 THE ABDOMEN. is present. The retention of secretion may lead to deep ulceration and gangrene of the prepuce. This condition is at times the first sign of the presence of a diabetes. EPITHELIOMA OF THE PENIS. This occurs late in life. It occurs usually in one of two forms, either as a cauhflowerdike growth (Fig. 226) or as an ulceration with under- mined and markedly indurated edges. The former is the more frequent. If it is present wath a ' tight prepuce the diagnosis may be made from the purulent discharge, : by palpating the induration through the intact prepuce, and by the in- durated, enlarged inguinal lymph- nodes. A httle later, when the tumor has penetrated the prepuce, the diagnosis is much easier. The dis- charge may be the first symptom which calls the patient's attention to his condition. The second or ulcerative form re- sembles somewhat the carcinomata of the hp with their craterdike ulcer- ation, indurated bases, and edges. In the differential diagnosis 0} the cauliflower form one must consider venereal warts. These are softer and there is no induration of the base or of the inguinal lymph-nodes. From the ulcerative form one must differentiate a chancre and a gum- ma. In neither of these are the edges or base as hard as in carcin- In chancre there may be enlargement of the inguinal nodes, but they are never as indurated, and the primary lesion is followed by other secondary symptoms within a few weeks. If any doubt exists, the administration of antisyphilitic remedies will soon clear up a chancre. In the case of a gumma of the penis the same clinical findings hold Fig. 226. — Typical I'apillary Carcinoma of Prepuce Perforating Outer Layer . of Same. oma. THE TESTIS — ABNORMALITIES IN DEVELOPMENT. 387 true. The edges or base are never as indurated, there are no enlarged inguinal nodes, and there is usually the history of syphilis or evidence of its presence elsewhere. The administration of potassium iodid should cause a marked differ- ence in the appearance of the ulceration within a week. The Testes. abnormalities in de- velopment. A lack of develop- ment of the testis may occur in an imperfectly or in a perfectly de- scended testis. It is more frequently associ- ated with the former, but it must not be as- sumed that every testis which has not reached the scrotum is incapable of producing healthy spermatozoa. The latter property is, however, lacking in the majority of such cases. Such non-developed testes may not show any perceptible decrease in size, but usually they are much smaller than the normal organ. One can recognize such non-development clinically by the absence of many of the male characteristics, the lack of pubic hair, the infantile size of the penis and scrotum (Fig. 227), the smooth, soft, child-hkc, hairless skin and fat of the entire body. In some cases this so-called infantilism is accompanied by a high-pitched, almost feminine voice, and in the case shown in Fig. 227 there was a lack of mental development. The term "atrophy of the testis" should be confined to those cases in which the organ has been normally developed, but has undergone retrograde Fig. 227. — Infantilism in a Patient, Thirty Years of Age, Due to Non-development of Testes, with Normal De- scent OF these Organs. 388 THE ABDOMEN. changes, as may occur after acute inflammations, such as the orchitis fol- lowing mumps or injuries. Occasionally such atrophy may take place after operations for inguinal hernia, or in a moderate degree as a result of a marked varicocele of long standing. IMPERFECT DESCENT OF THE TESTIS AND ITS COMPLICATIONS. If the testis is arrested in its migration from the abdominal cavity to the scrotum, the condition is called non-descent or retention of the testis. If it has pressed through the inguinal canal and then assumes an abnormal position, it is called an ectopia or ab- normal descent. In the case of the re- tained testis the organ may be arrested (a) within the abdomen, {h) in the ingui- nal canal (Fig. 228), and jM|| 2 o ^ Wg\ (^) J^^^ below the external ^^^ ^ j^ JH abdominal ring (Fig. 228). ^^^ ^ fi ^' IPH In ectopia testis the organ has been found beneath the skin of the anterior abdominal wall, in the femoral region (Fig. 229), in the perineum (Fig. 230), at the root of the penis or toward the anterior supe- rior spine of the ilium. In examining a child for a retained testis, it must be remembered that children possess the ability to draw the testis, even when normally descended, into the ingui- nal canal almost as far as the internal ring (Fig. 231). The presence of a retained or abnormally descended testis may be readily recognized by first palpating the scrotum, when one or both sides will be found empty. Careful search should then be made, in the places where the testes are usually retained or abnormally placed, for a soft, oval, easily movable tumor corresponding to the testis. In children the organs may be retained in the inguinal canal until near puberty and then suddenly descend. An abnormally retained testis cannot be palpated, and the first sign of its presence may be an inflammation. Fig. 228. — Most Frequent Locations of Testis in Cases OF Non-descent. I, Location of testis within inguinal canal; 2, location just outside of external abdominal ring. The third most frequent position (abdominal testis) is not shown in the picture. IMPERFECT DESCENT OF TESTIS AXD COMPLICATIONS. 389 The following conditions may develop in or accompany a retained or abnormally descended testis : Inflammation. Torsion of the cord (Fig. 232). Tumor formation. Hydrocele and hernia. Inflammation.— This is especially apt to occur in an imper- fectly descended testis, often from torsion of the cord. The situation of the local inflammatory signs (pain, swelling, etc.) varies according to the location of the organ. The pain is more intense than in intlam- ■"Tn-y" rm ' i' ' y/f ' "^ % Fjg. 229.— Location of Testis es; Femoral Region (Eccles). The testis is arrested over Scarpa's triangle; the left side of the scrotum is atrophied. mation of the normally placed organ, and is apt to be accompanied by nausea and vomiting greatly resembling a strangulated hernia or an in- flamed lymph-node if located in the femoral or inguinal regions, If situated within the abdomen the condition may resemble an appendicitis or some other acute abdominal condition. In inflammation there is an absence of the testis in the scrotum on the affected side, the onset is not as sudden, nor do the nausea, vomiting, or constipation, if present, persist as they do in strangulation. The local tenderness and swelling are also more marked in an inflamed testis and there is more apt to be fever and leukocytosis early. From an inflamed lymph-node the diagnosis is not as difficult. 39° THE ABDOMEN. There is usualh' some primary focus for the enlarged node to be fomid, the testis is present on the inflamed side, and the sweUing is more super- ficial than in an in- flamed testis. 2. This has been discussed on page 274. 3. Tumor For- mation, — It has been commonly believed that tumors were more likely to develop in an imperfectly descended testis, but Eccles, who has examined 854 cases of this condition, believes that malig- nant disease is not more frequent than in the normally de- scended organ. It is well to remember that a gradual enlargement of an inguinal tumor, if the testis on the same side has not descended into the scrotum. Fig. 230. — Left Testis in Perineum of an Infant (Eccies). T T Fig. 231. — Normal Power of the Cremaster Muscles in Children of Drawing Testis through ExTEEN.^L Abdominal Ring into Inguinal Canal. T, Testes outlined on surface of both, showing how they were drawn up from the scrotum in a boy of seven, as far as the e.xtemal abdominal ring. The small size of the scrotum is due to the absence of both testes. INFECTIONS OF THE MALE REPRODUCTIVE ORGANS. 39^ must be regarded with suspicion. The first sign of its malignant char- acter may be the evidence of a distant bone metastasis. Hernia and Hydrocele in Connection with Imperfect Descent.— Hernia occurs in about one-half of the cases of undescended testis and is most often of the con- genital inguinal variety. Hydrocele is also a frequent accompaniment. INFECTIONS OF THE MALE REPRODUCTIVE ORGANS. For diagnostic purposes it will be found of service to include the diseases of the vas deferens, seminal vesi- cles, and prostate with those of the testis and epididymis, since in many of the cases of pathologic conditions of these latter there are co- existing changes in the three first-named structures. This is especially true of gonorrhea (page 382) and tuberculosis. One of the most impor- tant lessons to learn before attempting to make a diag- nosis of these conditions is to practise palpation of the same structures either on the non-affected side or in normal individuals. A physician must accustom himself to the consistency and relations to each other, of the body of the testis or orchis proper, and of the epididymis. In the latter one must learn to distinguish the head or upper pole from the tail or lower pole. The vas deferens should also be palpated and followed toward the external abdominal ring. By rectal examination the normal prostate may be palpated. The seminal vesicles cannot be felt unless enlarged. The best position for an examination of the testis and epididymis is to palpate the organs of the right side with the left, and vice versa (Fig. 233). Fig. 232.- -Strangulation of a Testis Due to Torsion OF ITS Cord (Eccles). The darker patches indicate extravasation of blood into its substance. This condition was present in a case of non- descent of the testis, the latter being arrested in the inguinal canal. 392 THE ABDOilEX. The chief pathologic conditions of these structures which are of clinical interest can be conveniently divided for diagnostic purposes into two classes, as follows : Acute (Fig. 235). Chronic (Fig. 236). 1. Gonorrhea most often involves tlie epi- i. Tuberculosis in early stages involves didymis and vas deferens, rarely the first the head of the epididymis, body. later the entire epididymis and vas. Rarely does it begin acutely or as- 2. Trauma usually causes enlargement of sociated with gonorrheal epididy- body of testis or orchis proper, rare- mitis. ly of the epididymis. 2. Syphilis in majoritj- of cases involves body 3. Enlargement joUo'u.'ing epidemic para- or orchis proper. Epididymis rare- titis {mumps) always involves body ly involved alone or in conjunction of testis or orchis proper. with orchitis. Gumma of vas de- ferens quite rare. 4. Cystitis of non-gonorrheal origin may he followed by an epididymitis (es- 3. JYeo^/a5;Hj, whether benign or malignant, pecially with enlarged prostate). always begin in the orchis proper or bodv of testis. Typhoid and influenza rarely are fol- lowed by an epididymitis. The above table holds true for the majority of cases. Cases will be met with, however, in which a tuberculosis may begin ver\' acutely or develop upon an acute gonorrheal epididAinitis, or the exceptional cases referred to under syphilis may occur. In general, however, such a table will be found a convenient guide. The principal diagnostic features of these various affections follow\ Gonorrheal Epididymitis and Orchitis. — This occurs in the second or third week of an acute attack or in the course of a chronic case after the passage of sounds or massage of the prostate. The epididymis is greatly and uniformly enlarged and tender. The structure rests like a cap upon the orchis, and the latter can be distinctly felt unless an acute gonorrheal hydrocele (periorchitis serosa acuta) coexists; then a double enlargement with a depression between is to be felt (Fig. 235). The existence of an acute urethritis, in the pus of which the gonococcus can be demonstrated, confirms the diagnosis. The tem- perature varies from 101° to 104° F. The vas deferens is greatly enlarged and very tender. The disease may occasionally begin with severe pain along the intra-abdominal portion of the vas deferens. When an epi- didymitis sets in, the urethral discharge usually ceases temporarily. The epidid}TTiis remains enlarged and tender at times for months after an attack. Abscesses may form, especially after a gonorrheal orchitis. Less often is the orchis or body of the testis involved in a gonorrheal TRAUMATIC AFFECTIONS — TUBERCULOSIS. 393 inflammation. One can then feel a smooth, oval, tender, scrotal tumor, upon which the epididymis rests, unless an acute hydrocele obscures it. TRAUMATIC AFFECTIONS. These usually affect the body of the testis, especially after a kick or blow on the scrotum. The epididymis or vas deferens may occasionally be inflamed after heavy hfting. If they result from lifting some heavy object, the epididymis may be most involved. The diagnosis can be readily made from the history, the palpatory findings, and the exclusion of gonorrheal infection. Fig. 233. — Method of Examining the Vas Deferens on Either Side. The examination of the right vas deferens or veins of the spermatic can be best carried out by standing either in front or upon the right side of the patient, and grasping the structures between the index-finger and thumb of the left hand. The same method may be followed in the examination of the vas deferens for sper- matic veins on the left side by grasping it between the right thumb and index-finger. TUBERCULOSIS. This disease most often begins in a slow, insidious manner. A num- ber of cases have, however, been reported of a very acute development, especially in children and young adults. The author has reported a typical case in which it followed an acute gonorrheal epididymitis without perceptible interval. The testis is usually involved at a later period, so that it is possible at such a time to find that the testis and the epididymis are involved to such an extent as to feel like a continuous body through the scrotum. 394 THE ABDOMEN. Fig. 234. — Localization of Gonorrheal Infection in the male Genito-urinary Organs (Semidia- grammatjc). K, Parenchyma of kidney; Py, gonorrheal pyelitis; Ut, gonorrheal ureteritis; the arrow points the direction in which the infection ascends from the bladder to the kidney; B, bladder wall; the arrow at the neck of the bladder indicates the direction of the infection from the urethra to the bladder (gonorrheal cystitis) ; UP, seat of posterior urethritis; M, infiltration of urethral walls at bulbo-membranous junction — most frequent seat of gonorrheal stricture; UA, anterior urethra; T, triangular ligament, which divides the urethra into the anterior and posterior portions. Os symphysis pubis, from which triangular ligament is suspended; PA. periurethral abscess; B, balano-posthitis; Ty, inflammation of Tyson's gland; P, seat of prostatic abscess, pointing toward the perineum, involving bulging of the anterior wall of the rectum; R, rectum; the arrow shows the direction in which infection occurs, causing a gonorrheal proctitis; V — D, seat of the vas deferentitis; E, seat of gonorrheal epididymitis; Or, orchis, or body of testis; H, seat of acute gonorrheal hydrocele; Mu, musculature of abdom- inal wall; S, seminal vesicles, the seat of gonorrheal vesiculitis; the arrow shows how transmission is effected from the posterior urethra to the seminal vesicles and vas deferens, from the latter to the epididymis, etc. TUBERCULOSIS. 395 c. Fk;. 23s. — Differential Diagnosis of Acute Enlargements of the Testis and Epididymis. a. Normal testis, b, Gonorrheal epididymitis and vas deferentitis. Note the marked enlargement of the epididymis and spermatic cord as compared to the normal structures, and how the epididymis almost encloses the testis, c. Acute gonorrheal epididymitis, deferentitis and acute gonorrheal hydrocele, d, Acute orchitis following trauma of the testis, and the characteristic enlargement of the body of the testis (orchis) following mumps, and other infectious diseases. 396 THE ABDOMEN. Fig. 236. — Differential Diagnosis of the Chronic Enlargejients of the Testis and EpiDiDVMrs. a, Syphilis of testis. This is one of the two forms in which syphilis affects th-e testis. In this variety both testis, that is, the body of the testis (orchis), and epididymis are enlarged. (See text.) b, Second variety of syphilitic affection of the testis. In this form the orchis or body of the testis is predominantly enlarged, giving rise to a large tumor, syphilitic orchitis, or sarcocele. c, Tuberculosis of the testis. This illustration shows the most frequent localization of tuberculosis, especially in its early stages, involving especially the tail of the testis and the vas deferens, in the form of a nodulated enlargement of the former, and a beaded one of the latter, d, Tumors of the testis. This illustration shows how tumors, both benign and malignant, of thetestis almost exclusively affect the body of the testis. TUBERCULOSIS. 397 The disease may follow trauma as well as gonorrheal inflammation or foci of tuberculosis elsewhere. A search for all of these should be made in every case. In the majority of cases the disease begins slowly. One or more hard nodules can be felt in the upper part of the epididymis, so that it feels very irregular. Later a similar condition of the entire epididymis can be felt and the vas deferens is thickened and bead-like on palpation. Early abscess formation and formation of a sinus in the scrotal skin, with discharge of thick, cheesy pus, speak for tuberculosis. i\n examina- ^■■r^" " RTE ""^iiBi' ''^^' ^m ^^■^R^ :^^_„- _^,..-^--PA ^H ^^B "^^ 1 m ' "^ "^ v^ "^'^ • .Aj^i^I^BWlj^ ~ '**'^"'**^^ Fig. 237. — Complications Following Gonorrheal Urethritis. PA, Periurethral abscess grasped between the thumb and index-finger; S, collection of serum between periurethral, abscess and acute gonorrheal hydrocele (H); RTE, inflamed epididymis of right testis: LT, left testis. tion of the prostate and seminal vesicles will show hard nodules in many cases. If the disease is advanced, tubercle bacilli may be demon- strated in the urine, as referred- to, in the diagnosis of renal tuberculosis. It is rarely necessary to resort to a tuberculin test and reliance can seldom be placed upon a negative result after the use of tuberculin. Tuberculosis must be differentiated from a chronic enlargement which may be a sequel of an acute epididymitis. The induration of such a chronic epididymitis is usually diffuse and tender, the vas is smooth and firm, and the history of a previous acute gonorrheal attack and exam- ination of the urine, will clear up any doubts. In those cases referred 398 THE ABDOMEN. to above, in which the tuberculous condition develops directly upon a gonorrheal, the diagnosis can only be made from the more nodulated outline in tuberculosis, and similar nodules in the vas and prostate, or by the discovery of the tubercle bacilli in the urine or in the pus of a sinus, if one exists. Syphihs usually affects the body of the testis and but rarely the epi- didymis. The induration is not nodulated if it affects the epididymis, and the history and the administration of potassium iodid will render a differentiation possible. Fig. 238. — View from the Front of Conditions Illustrated in Fig. 237. The limbs of the patient were widely separated in order to take the photograph. PA, Periurethral abscess; S, collection of serum at lowermost portion or scrotum; H, acute gonorrheal hydrocele; RT, in- flamed right epididymis; LT, inflamed left testis. SYPHILIS. A gradual, almost painless enlargement of the body of one or both testes occurs. An acute onset with pain, is very rare. The enlarged orchis can be readily felt as an oval, smooth, painless tumor in the scro- tum. The epididymis and vas are rarely involved. In one case, in which such a complication occurred, I was able to differentiate it from tuberculosis by the absence of nodulation and the more diffuse character of the induration, as well as the history and the absence of sinuses. The existence of a large accompanying hydrocele may at times obscure the existence of a syphilitic orchitis until the fluid is evacuated. NEOPLASMS OF THE TESTIS. 399 TUMORS OF THE TESTIS AND EPIDIDYMIS. These may be divided into: Benign. — (a) Spermatocele, (b) Adenoma and cystadenoma testis, (c) Dermoids and teratoma. Malignant. — {a) Sarcoma. (&) Mixed tumors. SPERMATOCELE. This form of tumor, which is really a retention cyst of the epididymis, can be felt as a tumor which grows slowly to the size of an adult fist. The tumor either shows distinct fluctuation or is quite tense. It can be felt as either separating the testis proper from the epididymis or it feels like a hydrocele. It can be recognized on exploratory puncture as a spermatocele by its milky contents, which contain spermatozoa. NEOPLASMS OF THE TESTIS. In the diagnosis of neoplasms of the testis two questions present themselves: (i) Is the enlargement of the organ a neoplasm? (2) What is the nature of the new-growth ? In answering the first question, it is necessary to first determine by palpation whether the body of the testis or the epididymis is involved or whether the enlargement is one of the tunica vaginahs, e. g., hydrocele, hematocele, etc. If the enlargement is found to be of the epididymis alone, the question of a neoplasm need not enter into consideration, since the principal en- largements of this structure are due to gonorrhea, syphilis, and tubercu- losis (see page 392). If the enlargement is of the body of the testis the chief condition to be differentiated from a neoplasm is syphihs. In cases where there is a clear history of this latter condition the diagnosis will present no diihculties. The syphihtic enlargements are more stationary, showing but httle tendency to an increase in size. The only variety of neoplasm which causes such a gradual enlargement of the testis is the benign adenocystoma, but even in this form the increase in size is more progressive than in syphihs. The patients will usually give the history of a more rapid enlargement than in the case of syphihs. The admin- istration of potassium iodid for a week will usually clear up the diag- nosis in those cases in which the history is not clear and there arc no other evidences of syphilis to be found in the body. A malignant neoplasm of the testis can be readily distinguished from syphilis by its rapid growth. 400 THE ABDOMEN. A hydrocele can be differentiated by the absence of enlargement of the body of the testis, by the translucency test (Fig. 239), and by the use of the aspirator or trocar for the withdrawal of some of the hydro- cele fluid. At times it is almost impossible to difl"erentiate a hematocele from a neoplasm of the testis. In the latter the tumor is heavier and there is an absence of inflammation and of syphilis, the latter being the most fre- quent cause of a hematocele, also called periorchitis hemorrhagica. The second question to be answered is, What is the nature of the neoplasm ? Tumors of the testis may be divided into two great groups — benign and malignant. The benign are the adenocystomata, which are the most frequent, and the rarer forms, such as dermoid cysts. Of the latter only a few cases have been reported. The malignant varieties belong either to the sarcomata proper or to the so-called mixed tumors recently studied by Wilms. The majority of the cases of sarcomata of the testis belong to the small round- celled or spindle- celled varieties. They grow very rapidly, often appear simultaneously in both testes, and spread along the spermatic cord and inguinal lymph-nodes to the retro- peritoneal nodes. ^Metastases appear very early. The mixed tumors contain muscle fibers, cartilage, myxomatous tissue, glandular acini, bone, and blood-vessels in var\'ing proportions and combinations. Many text-books speak of cases of carcinoma, but their existence is denied by other equally good authorities. Clinically, the only distinction between the benign and malign-ant neo- plasms is their rate of growth. The malignant varieties, especially the sarcomata, cause so rapid an enlargement of the body of the testis that a diagnosis can be readily made. Accompanying this increase in size there is involvement of the spermatic cord and inguinal retroperitoneal lymph-nodes, all of which can be determined by palpation. Sarcomata are most common in children before the age of ten, and again in adults between thirty and forty. In the benign varieties of neoplasms of the testis the oval shape of the testicle is preserved. As the gradual in- crease in size occurs the surface becomes nodulated and softer in places. The mixed tumors form a clinical group by themselves. They cause, at times, a gradual enlargement of the testis; at others, a ver}- rapid one. After their removal they are most apt to cause metastases in the lungs and bones (Fig. 408J. HERNIA. 401 Hernia. A hernia may be defined as the abnormal protrusion of a visciis jrom any preformed cavity of the body. The term is, however, Hmited to those protrusions in which a portion of the abdominal viscera escapes through openings in the muscular or bony wall. The opening through which a hernia escapes is called the hernial ring or rings (if there are two, as in the case of the indirect inguinal). The most frec^uent varieties of hemi^e are the inguinal (73.4 per cent.), Fig. 239. — Method of Determining the Tkansldcency of a Scrotal Tumor in Order to Make a Diagnosis of Hydrocele from that of a Solid Tumor of the Testis or from a Hernia. An electric lamp or candle is held on the distal side of the tumor, while the examiner places a roll of paper or a cyUnder against the scrotal tumor on the side opposite to that on which the light has been placed. In case of a hydrocele, the hght is readily transmitted through it. the femoral (18 per cent.), and the umbilical (8.47 per cent.). The frac- tion remaining — i. e., 0.12 per cent. (Eccles) — represents the ventral, obturator, sciatic, lumbar, perineal, vaginal, and diaphragmatic varieties in the order named. The contents of a hernial sac are most often in- testines and omentum. Gurgling and tympany speak for the former, while a nodulated surface and dullness on percussion speak for the latter (omentum). Among rarer contents may be mentioned: (a) Ovary (increases in size and becomes more tender during menstruation) ; (b) testicle, feel- 26 402 THE ABDOMEN. 3w o H O H (« ■< W St3 O fl ii 1^1 ni ;r3 O . cd ^ OJ bC O n; bb oT 13 o ^ k tf) f^ c ^ u o s bJD o (J _d" '3 d O u O ni d c^ ^ o -^^ « a; -13 In bD d d d d o > rt OJ J^ d cd ^ hJ PLH O P^ cq fe bc-^ d .td •^ d ;3 oj d tjj U '^ ^ d t3 d >-^ oJ ^ =^ 5 S b >^ <" ^ -^ 2 o <-i s T^ t:) O S.2 U ^ o a.;d.d bC ^ 6 . d o 'Sb CJ rd bO d o U O- rt ^ OJ s en s M M •O bfl .5 'd d 1— 1 o u .s bi d o d o a. i2 to ^ d § aj § « « P % % p^ d .2 'bO d S y d _d OJ "to s 8 S G « Q W WW "d >-< d u d o u • S br d d bD d .add, (U O s s CO aj d o 6 d o w Q ^ ^ bb d ^^ p (U a. is d CO 1— 1 ►^ p^ d d o ing smooth, firm, and like a plum; (c) vermi- form appendix; ((/) urin- ary bladder; [e] uterus or tubes; (/) Meckel's diverticulum (Fig. 1 58) ; {g) rarely the stomach, liver, or spleen. A hernia is said to be reducible when its contents can be returned into the abdominal cav- ity upon gentle manipu- lation or when the pa- tient lies down. It is said to be irreducible when the above tests re- sult negatively. The following com- plications of both redu- cible and irreducible hemiae may occur. They are more frequent in the irreducible variety. 1 . The lumen of the bowel becomes obstruct- ed from within through stagnation of feces. This is called an incarcerated or obstructed hernia. 2. The sac wall or even the contents (es- pecially omentum) be- come acutely inflamed from causes both within and external to the sac. This is called an in- ■flamed hernia, and if it occurs in the redu- cible variety, adhesions form and produce irre- ducibilitv. HERNIA. 403 3. Strangulated hernia. In this complication there is interference with the passage of feces through the intestinal contents and secondary gangrene of the bowel wall as the result of interference with the circula- tion. Strangulation most often follows a sudden increase in abdominal pressure, as in coughing, lifting, straining at stool, etc. Fig. 240. — Location of Various Forms of Abdominal Herni.e (Diagrammatic). U, Umbilical hernia; D. direct inguinal hernia; B, indirect incomplete inguinal hernia; O, complete or scrotal inguinal hernia; F, femoral hernia. The principal diagnostic points of reducible and irreducible hemiae and their complications are given in the table on page 402. It is very difficult to differentiate between an obstructed and a strangulated, and, again, between an inflamed and a strangulated, hernia, since acute strangulation may occur in an obstructed hernia and the inflammation may spread to the general peritoneal cavity from an in- flamed hernia. At the present time operation is indicated in ever}^ case of irreducible hernia accompanied by local signs, such as pain, ten- 404 THE ABDOMEN. demess, and constipation, or nausea and vomiting. Hence the above differential points have often only a theoretic value. Emphasis cannot be too strongly laid upon the danger of forced taxis in the efforts to reduce an irreducible hernia for the purposes of diagnosis or treatment, whether or not such a hernia be accompanied by signs of inflammation or obstruction. In the table on page 402 attention is called to the fact that strangula- tion of only a portion of the wall of the gut (acute partial enterocele ^) may occur, causing far less marked symptoms of intestinal obstruction than if the whole circumference be strangulated. The same atypi- cal clinical picture may appear if the appendix or, as rarely occurs, a Meckel's diverticu- lum is strangulated. As in acute partial enterocele, the bowels may move normally or there may even be diarrhea. Here locahzed tenderness over the hernial region is the most valuable sign. Other atypical forms are: fa) When strangu- lation occurs within the sac or (h) w^here it takes place in a multiloculated sac. In both of these the impulse on coughing may be retained. Again, two or more irredu- cible hemiae may coexist, as in the case sho\\Ti in Fig. 252 (femoral and inguinalj . It is then difficult to say which has been strangu- lated. But in all of these anomalous forms the local tenderness is the most important symptom. ^J' Fig. 241. — Left-sided Congenital Complete In- guinal Hernia in a Boy of Eight. Note the location of the testis at the lowermost portion of the scrotum. INGUINAL HERNIA. This may be of three varieties : 1. Indirect or oblique. 2. Direct. 3. Interstitial. ' This form of partial strangulation of a gut has also been called a Littre hernia. INGUINAL HERNIA. 405 I. Indirect or Oblique Inguinal Hernia. — As long as the sac andjits contents remain within the inguinal canal this form is caUed an incomplete indirect or obhque inguinal hernia or bubonocele. When the sac and its contents protrude through the external ab- dominal ring (Fig. 241) into the scrotum, it is called a complete or scrotal hernia. The incomplete form may be recognized as a swelling which causes Fig. 242. — Method of Invaginating the Scrotum in Order to Determine the Size of the External Abdominal Ring. When examining the left external abdominal ring, as in the illustration, the left index and middle fingers of the examiner should be used. This can best be done when the patient stands upon a chair. The scrotum is then invaginated, until the index-finger feels the spine of the pubis, to the inner side of which the oval opening of the external abdominal ring, which in adults normally admits the index-finger, can be distinctly felt. The impulse of a hernia can be best felt in this manner. The patient is instructed to cough while the index-finger is placed in the external abdominal ring. a prominence along the course of the inguinal canal (from the internal to the external abdominal ring). The swelling has all of the characteristics of a reducible hernia, viz., that it causes a swelling in a hernial region' having all the properties referred to on page 402. There is a distinct impulse to be felt on coughing (Fig. 242). The swelling becomes more visibly prominent when the patient coughs or strains or stands up. It can be caused to disappear by hght taxis or when the patient lies dovm. The impulse is often best felt by invaginat- 4o6 THE ABDOMEN. ing the scrotum and inserting the index-iinger (Fig. 242) through the ex- ternal ring into the canal. When the hernia is of the complete or scrotal variety the position of the swelling at the upper end of one side of the scrotum, passing up into the groin on the outer side of the pubic spine, is typical. It can usually be readily reduced upon lying down and caused to reappear when ^ the patient coughs. The size of the external ring varies according to age, and to some extent in different individuals. In general, it admits the in- dex-finger in adults and the little finger in chil- dren. In inguinal hernias, especially if they are of long standing, the ring will often admit three to four finger-tips. The in- ternal ring cannot be felt. If the hernia has existed for many years, the external and internal rings may come to he op- posite each other, so that after the contents are re- duced, the finger inserted through the external ring seems to sink directly to- ward the peritoneal cav- ity, there being no pos- terior wall to the canal. This variety is called a straight hernia. An in- guinal hernia may be so large that no trace of the penis is to be found (Fig. 243). 2. Direct Inguinal Hernia. — A direct inguinal hernia appears at the outer edge of the rectus and is usually much smaller than the obhque form and more rounded (Fig. 240). It is very difficult to distinguish it from the above mentioned straight hernia, having the same palpatory findings and occurring, like it, in elderly people. It is almost impossible Fig. 243. — Enormous Double Inguinal Heeni..e. The right was reducible, but the left was irreducible. The depression in the center of the scrotal mass shows the atrophy of the penis, the organ being entirely hidden in cases of large herniae. The illustration also shows an enormous layer of abdominal fat, which the patient was able to pick up in his hands, in order to have the hernia photographed. INGUINAL HERNIA. 407 to state positively that the hernia is a direct one in such cases until at operation the deep epigastric artery is found along the outer border of the sac. 3. Interstitial Hernia. — There are three varieties of this form (Fig. 246) and it usually accompanies non-descent of the testis. The first variety is that in which the sac Hes between the internal and external oblique muscles. This variety is more common on the right side of the body and causes an oval swelling parallel to and directly above Pou- part's hgament. It does not project much from the surface and some of Fig. 244- — Typical Appearance of a Case of Left-sided Complete Oblique Inguinal Hernia. Note the depression between the lower border of the hernia and the upper border of the testis. the sac may pass into the scrotum or labium, so that a groove appears between the two parts of the hernia. In the second variety the sac hes between the external oblique apo- neurosis and the skin. The swelling has the same position as in the first form, but there is more projection from the surface. In the third variety, or propcritoneal hernia, there is almost always a part of the sac in the labium or scrotum (Eccles). It is seldom recog- nized except when strangulated or during radical cure operation. Unusual Contents of Inguinal Herniae. — Hernia of the Bladder.— This occurs oftencrin connection with an inguinal, than in femoral hernia. 4o8 THE ABDOMEN. The most frequent variety is where the peritoneum covering the bladder forms a part of the sac. Fig. 245. — Method of Palpating the Spermatic Cord ix Order to Make the Diagkosis of Complete Oblique Inguinal Herxl\ aeter Reduction of the Contents of the Sac. (See text.) Fig. 246. — Various Forms of Interstitial Herni.e. I, Subaponeurotic; 2, subcutaneous; 3, properitoneal (Eccles). 5, Skin; EO, e.xternal oblique aponeurosis and muscle; 10, internal oblique muscle; T, transversalis muscle; P, peritoneum. A diagnosis may be made before operation if the patient gives the history of the tumor disappearing during micturition, and if when pres- sure is made over it, the patient experiences a desire to urinate, or if the INGUINAL HERNIA. 409 act of micturition ceases suddenly and begins again as soon as the hernial swelling is compressed. Vermiform Appendix. — The presence of this structure cannot be rec- ognized before operation unless it should become inflamed or strangu- lated. The symptoms of the latter are less marked |. j ,..> J^ than in a strangulation of '"v < M the intestine proper. " T\ Ovary. — Before pub- erty its presence may be suspected if an oval, firm, freely movable tumor be found in the inguinal canal or just external to it. Later in life the ovary can only be recognized before operation if a firm body is found in the hernial sac, which swells and becomes quite tender during men- struation. I. Differential Diag- nosis of Inguinal Hernia in the Male. — i. When Reducible and Complete. — (a) From femoral hernia the following table will best illustrate the chief points of difference : Fig. 247. — Inguinal Hernia with Undescended Testis. Inguinal. Emerges on inner side of pubic spine. Inguinal canal filled and pubic spine ob- scured, when descended. Easily recur after reduction. Impulse felt above Poupart's ligament. Femoral. 1. Emerges on outer side of spine. 2. Inguinal canal empty and pubic spine to be felt. 3. Do not so easily recur. 4. Impulse below Poupart's ligament. (b) From a congenital or acquired hydrocele and from an undescended testis lying just outside of the external abdominal ring. In the last named condition the testis of the corresponding side is felt, just beneath the external abdominal ring (Fig. 228), as a firm elastic body a httle smaller than the normal testis. There is no impulse on coughing and the swelling cannot be reduced. Not infrequently a hernia is associated with this condition, so that a swelling is felt above the testis, which emerges from the inguinal canal on coughing and dis- appears upon manipulation or upon lying down. (c) The following table shows the differentiation of a congenital 41 o THE ABDOMEN. hydrocele, and acquired hydrocele and a reducible inguinal hernia (see Figs. 239, 245, 249) : CoiiPLETE Inguinal Hernl4 (Reducible). coxgexital Hydrocele. Acquired Hydrocele. I. Location. 2. Impulse 3. Translucency 4. If reduced. 5. Relation to testis and cord 6. Palpation and per- cussion Swelling continuous with inguinal region. Distinct on coughing. Not translucent, as a rule. Rarely so, in children (Fig. 241). Feel gurgling if con- tains intestine, reap- pears rapidly on coughing. Lies above or in front of testis (see Fig. 244) and in front of cord. Soft semi-elastic; dull if omentum; tjon- panitic if intestine. Same as in hernia. Swelling terminates at upper end of scrotum, can feel cord above tu- mor (Fig. 250). Xo impulse. No impulse. Translucent. Translucent (Fig. 239) unless greatly thick- ened sac. Reduction ven,' Cannot be reduced, slow. Reap- pears slowly. Same as in hernia. Lies in intimate relation j to testis, latter felt usu- ! ally below and behind tumor. Harder and more Pear-shaped swelling; tense; dull on harder and tense; dull percussion. j on percussion. 2. When Complete and Irreducible. — The following conditions must be considered in making a diagnosis: In the male: (a) Hydrocele of the tunica vaginahs (acquired hydrocele). (b) Hydrocele of the cord (encysted hydrocele — Fig. 249). (c) Hematocele. (d) Enlargements of the testis. In the female: (a) Hydrocele of the canal of Nuck. (b) Hydrocele of the hernial sac. The chief differential points are considered in the accompanying table : CoiEPLETE Irreducible Hydrocele 07 the. Enlargements of Inguinal Hernia Tunica Vaglnalis. Testis. Inspection Tumor e.xtends through Tumor terminates be- Same as in hy- external ring into in- low external ring. drocele. guinal canal. Palpation Expansile impulse on No impulse. Feels No impulse. coughing. Feels soft tense and elastic. Firm, may be ir- if intestine; firmer if regular. omentum. Percussion Tvmpanv, if intestine. Dullness. Dullness. Relation to testis Testis is below and be- Testis cannot be dis- Can outline en- hind tumor. tinctly felt. largement of body or epididy- mis. Translucencv Negative except rarelv Positive unless tunica Negative. in young children (Fig. greatlv thickened. 239)- INGUINAL HERNIA. 411 A hematocele gives the history of trauma or syphiHs, and is not trans- lucent. In an encysted hydrocele of the cord one can often palpate the nodules and can ascertain their attachment to the cord. In a hydrocele of a hernial sac the tumor can be caused to gradually disappear by gentle manipulation and elevating the pelvis. 2, 5. 4. 5. ^-^[R viR. TV Fig. 24S. — Various Forms of Hydrocele. IR, Internal abdominal ring; ER, external abdominal ring; T, testis and epididymis, shown in black. 1. Congenital hydrocele. The cavity of the hydrocele sac (H) communicates directly with the peritoneal cavity. 2, Typical form of acquired hydrocele: H, Distended tunica vaginalis. 3, Acquired inguinal hernia and ac- quired hydrocele: S, Sac of hernia; H, hydrocele sac. 4, Hydrocele of funicular process. The process is closed at the internal abdominal ring, but is continuous below with the tunica vaginalis: P, Represents that portion of the sac lying within inguinal canal. 5, Hydrocele of cord: EH and EH, placed respectively within the inguinal canal and just outside of the external ring, represent the two loculi of a hydrocele of the, cord ; TV, normal tunica vaginalis. 6, Hydrocele o_f a hernial sac. AO, .\dherent omentum; HF, hydrocele fluid in lower portion of sac. In a hydrocele of the canal of Nuck, which is quite rare, the diagnosis can only be made if there is distinct absence of impulse. 3. When Irreducible and Incomplete. — In the Male: (a) From a retained inguinal testis. (6) From various causes of enlargement of the spermatic cord (en- cysted hydrocele, lipoma). 412 THE ABDOMEN". (c) From enlarged and inflamed lymph-nodes. (d) From a lipoma of the groin. (a) An inguinal testis can be readily recognized by its size and con- sistency. One should palpate the scrotum as a matter of routine in order to ascertain whether one or both testes have failed to descend. (b) From various sources of enlargement of the spermatic cord. An encvsted hvdrocele is tense and elastic and is intimatelv connected Fig. 249. — Conditions to be Considered in Differential Diagnosis of Hernia and Hydrocele. T, Testis; N, neck of hernial sacs; IR, internal abdominal ring; ER, external abdominal ring; TV, tunica vaginalis; App, appendix vermiformis; SO, omentum adherent to sac. i. Congenital incomplete inguinal hernia associated with non-descent of testis. 2, Complete congenital inguinal hernia associated with non-descent of testis. 3, Incomplete acquired inguinal hernia with normal testis. 4, Complete congenital hernia with normal descent of testis. 5, Direct inguinal hernia with normally descended testis. 6, Acquired inguinal hernia with normal descent of testis. 7, .Acquired inguinal hernia showing appendix as one of the con- tents of sac. 8, Acquired inguinal hernia with adherent omentum. with the cord. A lipoma of the cord is rare. It feels soft and doughy and may be lobulated. (c) Enlarged and inflamed inguinal lymph-nodes. These are quite superficial and are tender to the touch. There is often redness of the overlying skin and distinct fluctuation present. In doubtful cases search should be made for a primary source of infection in the external geni- talia, lower portion of the rectum and vagina, and lower half of abdominal wall. INGUIXAL HERXIA. 413 Fig. 250. — OxE or the Steps ix ^L\kixg a Differextial Diagxosis betweex an Acquired Hydrocele AND A Hernia. Grasping the spermatic cord between the inde.x-finger and thumb, to show that the scrotal tumor does not pass through the e'cternal abdominal ring. The hydrocele which was present in this case on the right side remains as a pear-shaped swelling, entirelj' below the lingers grasping the cord. Fig. 251. — Hernia and Hydrocele in the Same Patient. Hy, Hydrocele sac, pushing the testis (T) downward and behind it; He, left indirect complete or scrota hernia. (See text.) 414 THE ABDOMEN. In the Female: (a) Hydrocele of the canal of Nuck is uncommon. In many cases it is present as a reducible swelling in the inguinal region for a long period, and then suddenly cannot be displaced. It may have the latter property of irreducibihty from the first in some cases. It may be a unilocular or bilocular sac. At times it may become in- flamed and simulate a strangulated hernia, being accompanied by severe pain, tenderness, and vomiting. Fig. 252. — Inguinal and Femoral Hernia on the Same Side. I, Inguinal hernia, of the complete or scrotal type, which can be followed upward to where it enters the internal abdominal ring at the level of the middle of Poupart's ligament; F, femora! hernia. The depression between these two varieties of hernia corresponds to Poupart's ligament. FEMORAL HERNIA. A femoral hernia has the following clinical characteristics: The swelling in the majority of cases (Fig. 252) can be seen and felt as lying below or in front of Poupart's ligament and over the inner side of the front of the thigh. The impulse on coughing and the neck of the sac can be felt as lying on the outer side of the pubic spine. The swelhng is not so apt to occur so easily when reduced, and after reduction one can feel the pulsation of the femoral artery. The inguinal canal is empty FEMORAL HERNIA. 415 and no impulse on coughing can be felt after invaginating the scrotum and inserting the index-finger into the external abdominal ring (Fig. 242). In some cases of femoral hernia the swelling ascends and either lies in front of the inner half of Poupart's hgament or it passes upward and outward toward the anterior superior spine of the ihum. In many of these latter two aberrant varieties of femoral hernia, a differentiation from an inguinal hernia cannot be made except at the time of operation. It was formerly thought that a femoral hernia was rare in men, and that an inguinal hernia was similarly infrequent in the female. The foregoing statement has been proved by many clinical observations to be incorrect. The two varieties may coexist in the same individual. A femoral hernia, Hke an inguinal hernia, may be reducible and ir- reducible. It is more apt to contain omentum than the inguinal, and hence is more often irreducible. The following combinations may exist (see Fig. 253): 1. It may be completely reducible. 2. It may be possible to reduce the greater portion of the tumor and then a doughy swelhng remains which is usually a subperitoneal lipoma (Fig. 253) attached to the fundus of the sac. 3. It may be completely irreducible. The three chief conditions from which a reducible femoral hernia must he differentiated are: (i) Incomplete reducible inguinal hernia; (2) psoas abscess; (3) a varicose dilation of the internal saphenous vein just before it enters the saphenous opening. The first three are given in the accompanying table : Reducible Femoral Hernia. Incomplete Redu- cible Inguinal Hernia. Varicosity of Saphenous Vein. Psoas Abscess. I. Location of swelling Below Poupart's liga- ment. Above Poupart's liga- ment. Below Poupart's lig- ament and along course of saphen- ous vein. Below Poupart's, but mass also to be felt by deep pal- pation over Pou- part's ligament. 2. Impulse Distinct, and felt below Poupart's ligament. Distinct and felt above Poupart's ligament. Indistinct and dis- appears rapidly; more of a thrill. Indistinct and only when Ijing down. 3. Percussion Dull, if omentum; tym- panitic, if intestine. Same as in femoral. Dull. Dull. 4. Other signs. . . Reappears after reduc- tion; when coughs. Reduction backward and upward. Reappears after re- duction (outward, upward, and back- ward) ; when pa- tient coughs. Marked enlarge- ment of entire in- ternal saphenous vein. Kyphosis and rigid- ity of spine. Hip flexed. Occasionally a femoral hernia will contain the urinary bladder. 4i6 THE ABDOMEN. The diagnosis ^ is rarely made before operation, although suspicion should be directed to this possible contents when urinary symptoms appear in connection with a femoral hernia. The cystoscope may be of aid in showing the relationship of the bladder to the hernia. An irreducible femoral hernia must he differentiated from (i) an enlargement, of either an acute or a chronic nature, of the lymph-nodes lying over the saphenous opening; (2) from a lipoma; (3) aneurysm of the femoral artery. I. Inflamed or enlarged lymph-nodes lie quite superficially. If acutely inflamed, there are no symptoms of disturbance in the ahmen- tary canal, such as nausea, vomiting, tympanites, etc., as would be the case in an inflamed or strangulated femoral hernia. Fluctuation is often quite distinct and a primary focus of infection can be found by an exam- FiG. 2S3- — Normal and Complicated Femoral Herni.e. PL, Poupart's ligament; ER, External abdominal ring; A, anterior crural nerve; B, femoral arterj'; C, femoral vein; H, hernial sac. i. Most common form of femoral hernia. The sac lies to the outer side of the external ring and below Poupart's ligament. 2, Irreducible form of femoral hernia, duT to adhesions of omentum to interior of sac. 3, A reducible femoral hernial sac to which is attached an irreducible subperitoneal lipoma. ination of the lower extremity (toes, heel, sole of foot, leg, knee, etc.). The enlarged nodes can be moved upon the underlying tissues, while in an irreducible femoral hernia one can always feel (except in very stout persons) the neck of the sac. 2. A femoral lipoma has no impulse; it is often lobulated, and lies quite superficially. It must not be forgotten, however, that a large hpoma may be attached to an irreducible femoral hernial sac. Under these circumstances a differentiation is impossible before operation. 3. An aneurysm shows a distinct thrill, expansile pulsation, and a rough systohc bruit. In inflammation of the iliopsoas bursa there is pain on movement of the hip and the swelHng and tenderness lie quite deeply. ^ Karewski: "Archiv f. klin. Chir.," Bd. Ixxv. UMBILICAL HERNIA. 417 UMBILICAL HERNIA. There are three varieties of this form of hernia: (a) the congenital, (b) the infantile, and (c) the adult. Congenital Umbilical Hernia. — This occurs as the result of the non-coalescence of the two lateral halves of the abdominal wall. The most important form of a congenital umbiHcal hernia is that in which a coil of small intestine or Meckel's diverticulum projects through the base or root of the umbihcal cord. If the latter is tied too close to the body, the knuckle of intestine may be cut through and a septic peritoni- tis result. It is almost impossible to recognize this form unless the base Fig. 254. — Double Femoral Lipomata Simulating Femoral Herni.s (Eccles). of the cord looks broader than normal and can be reduced in size by taxis, the enlargement disappearing with a gurgle. The other two forms of congenital umbilical hernia are not difficult to recognize. In one form a large swelhng is found in which the presence of viscera can be seen through the thin translucent membrane which covers it. - The umbilical cord is found at the summit of the swelling. The sweUing usually contains only coils of intestine, but other viscera may be present. In the third form, which is quite rare, there is a complete eventration and the prolapsed viscera lie exposed without even a mem- branous covering. Infantile Umbilical Hernia. — These usually present themselves in infants, but may be found even in young adults. 27 41 8 THE ABDOMEN. Examination of the umbilical region reveals a conical swelling, over which there is a loose fold of skin. The protrusion is only noticeable when the child coughs or strains. When the swelhng is reduced the firm edges of the circular umbihcal ring can be felt by inserting the httle finger. Umbilical Hernia in Adults. — Chnically umbihcal hernia in adults appears either (a) as a small tumor usually lying just above the umbihcus ^^/M Fig. 255. — View of an Adult Umbilical Hernla in the Earliest Stage of its DEVELopiiENT. This illustration was made while the patient was lying down. The arrow points to the prominence situated just above the umbihcus proper (see text). The photograph was made while the patient was coughing, shomng the umbihcal hernia at its maximum size. (Fig. 255), or (5) as a larger one wliich is easily recognized and which pushes the cutaneous umbilicus forward (Fig. 256). Both forms are more apt to occur in stout persons, but the smaller variety may occur even in lean individuals and be the source of much discomfort. Such small umbilical herniae may give rise to recurring abdominal pain and various dyspeptic symptoms, and, the hernia being overlooked, the patient is often wrongly treated (D. D. Stewart). The best method of examination for both this variety of adult umbilical and for epigastric herniae is to inspect and palpate the median line of the UMBILICAL HERNIA. 419 abdomen while the patient coughs, first while standing up (Fig. 256) and then upon lying down. In many of the cases the hernia is assoc- iated with a properitoneal lipoma, as in the femoral herniae. Under these circumstances one sees a protrusion (even if only very slight) upon coughing and feels an impulse. Upon further examination it is found that the swelling does not dis- appear entirely upon ma- nipulation or upon lying down, but that a soft, often lobulated-mass can be felt. The latter is the small pro- peritoneal lipoma attached to the sac. These small umbilical hernia must be differenti- ated from fatty tumors of the linea alba. This can be done by the absence of an impulse upon coughing and the fact that manipu- lation or posture, such as lying down, does not cause the tumor to disappear. The larger umbihcal herniae present no difficul- ties of diagnosis. The swelling is rounded or transversely oval and often hangs down toward the symphysis (Fig. 256). The swelling is more often irre- ducible than the opposite. If the former is the case the tumor feels doughy and lobulated and is dull on percussion. The contents are usually composed of omentum firmly adherent to the sac and coils of intestine. Incarceration and strancjula- tion of these larger umbilical hernia are not infrequent complications. If symptoms of intestinal obstruction occur in stout persons one should never fail to examine the umbihcal region carefully. The characteristics of these complications (incarceration and stran- gulation) have been referred to on page 403. Fig. 256. — Side View of a Case of Umbilical Hernia. The coils of intestine and omental contents of this sac w.ere adherent to the interior of the sac, so that symptoms of incarcera- tion would appear from time to time. 420 THE ABDOMEN. VENTRAL HERNIA. These occur as an acquired condition, usually in the linea alba or linea semilunaris. They may occur spontaneously, or follow an oper- ation or a trauma such as a penetrating or crushing wound. I have described a case^ of the traumatic non-penetrating variety in which a swelling with unbroken skin appeared within a short time over the crest of the ihum in a patient who had been crushed between two cars. The abdom- inal muscles and peri- toneum had been torn from the crest of the ilium. The ordinary spontaneous variety of ventral hernia may be found above or below the umbilicus. When they occur in the med- ian hne above the um- bilicus they are spoken of as epigastric hernias. They are often the cause, like the small umbilical hernise, of re- current abdominal pain and symptoms of diges- tive disturbance. The diagnosis of these epi- gastric as well as of the other forms of ventral herniae is not difficult. In some cases there is no visible swelling and a diagnosis can only be made by passing the fingers along the median line and the semilunar hne while the patient coughs. The characteristic im- pulse and the appearance of a swelhng enable one to make the diagnosis. These ventral hernice may attain such a large size that practically all of the hollow viscera and omentum are contained in them. In very stout persons an enormous overhanging mass of fat will at first sight simulate such a hernia (Fig. 243). In every case presenting symptoms of chronic gastritis, gallstones,. or Fig. 257. — Method of Palpating an Epigastric Hernia. The finger-tips of the examiner should be placed successively upon different points in the linea alba from the ensiform downward and the patient instructed to cough. 'Annals of Surgery/' 1904. RARER FORMS OF HERNIA. 421 ulcer of the stomach one should examine for the presence of an epigastric hernia. A hernia following a laparotomy can be recognized from the history, the scar, and the signs characteristic of all reducible herniae, viz., a swell- ing which disappears, often with a gurgle, upon manipulation or upon lying down, and reappears with an impulse upon standing up or after exertion such as coughing, etc. RARER FORMS OF HERNIA. Obturator Hernia. — This form can seldom be recognized until symptoms of strangulation appear. The protrusion occurs through the obturator foramen and can occasionally be felt externally just below the pubes on the inner side of the femoral vessels. It may also cause pain, which is referred to the knee along the distribution of the obturator nerve. If strangulation occurs, the condition must be differentiated from rheuma- tism by the absence in the latter, of symptoms of intestinal obstruction, and from pelvic peritonitis, by the bimanual examination of the pelvis. Obturator herniae are most apt to occur in elderly females. Diaphragmatic Hernia. — This has been previously described in connection with injuries of the thorax (page 197). Lumbar Hernia. — This may occur anywhere behind the linea semilunaris and between the last rib and crest of the ilium. These herniae may be congenital or acquired, the former often being bilateral. The acquired form may be either spontaneous or traumatic. The former usually protrude through the triangle of Petit, just below the twelfth rib, as a swelling which has all the signs just referred to as typical of a re- ducible hernia. One must differentiate the spontaneous variety from a lipoma, and from a cold abscess due to disease of the spine. The traumatic variety may either follow an operation upon the kidney or some crushing injury, such as described under traumatic ventral hernia. The diagnosis does not differ from that of the spontaneous variety. Sciatic Hernia. — This occurs through the sacrosciatic foramen, forming a swelling in the gluteal region. Very few cases have been recorded of this variety of hernia. When the hernia is small it may escape recognition unless a careful examination for such symptoms as pain over the gluteal region be made. If the hernia is large it gives rise to a distinct gluteal swelhng with a marked impulse on coughing and re- ducibihty with a gurgling sound if intestine is present in it. It must be differentiated frorn an abscess due to hip disease, from a hpoma, and from an aneurysm. CHAPTER V. THE EXTREMITIES. Injuries of the Soft Tissues, Bones, and Joints. In attempting to make a diagnosis as to the nature of injuries received as the result, either of a recent accident, or of one sustained at some previous period, the following possibihties must be borne in mind, and each one ehminated by a process of exclusion, based upon a thorough examination and history of the case. These possible injuries and their complications are: INJURIES OF THE SOFT PARTS. Location. Nature. Possible Coiiplicatioxs or Re- sults. 1. Skin and subcu- taneous tissue, .(a) Penetrating wounds; lacer- (a) Infection with ordinary pyo- ated, punctured, incised, genie organisms (streptococci gunshot. and staphylococci). (b) Non-penetrating wounds or (b) Tetanus, contusions. (c) Erysipelas and erysipeloid. (d) Infection with gas-producing bacUli. (e) Anthrax. 2. ISIuscles Contusions, penetrating wounds, Traumatic myositis, myositis os- rupture of muscles. si&cans. Loss of function. 3. Tendons and ten- don-sheaths.. -Lacerated or incised wounds. Infective tenosynovitis, ganglion. Rupture of tendon, dislo- Loss of function, cation of tendons. 4. Bursae Contusions. Penetrating wounds. Acute suppurative and non-suppu- rative bursitis. 5. Blood-vessels Penetrating wounds or contu- Phlebitis. Gangrene of extremi- sions of arteries or veins. ties. Ulcers (trophic). Trau- matic aneurysms. 6. Nerves Contusions or penetrating wounds Neuritis. Paralysis of motion or of nerve-trunks or filaments. sensation or both. INJURIES OF THE BONES AND JOINTS. Location. Nature. Complications. 1. Bones Contusions or ' penetrating Periostitis or necrosis of bone. wounds of periosteum. Infection. Injur}' of nerve. Injury Simple or compound frac- of vessels. (Gangrene or an- tures. eurysm.) Coxa vara trauma- tica. 2. Joints Sprains. Penetrating wounds. Septic arthritis. Injury to carti- Dislocations: simple and lages or ligaments. Paralysis compound. of nerves. 422 INJURIES OF THE SOFT PARTS. 423 INJURIES OF THE SOFT PARTS. The most important points to be determined in the examination of an injury of the extremities are: (a) the location of the injury; (b) its nature or extent; (c) whether complications exist or not. In order to be able to answer these, a careful history must be taken of the man- ner in which the accident occurs, next the physical examination of the part involved, as well as the observation of the general condition. Injuries of the skin consist of either simple or complicated wounds. In the simple variety there is an injury of the skin and subcutaneous tissues alone, either {a) in the shape of a lacerated, incised, punctured, or gunshot wound, often called a penetrating wound, or (b) a collec- tion of blood in the subcutaneous connective tissue of greater or less extent, called a non-penetrating wound or contusion (bruise). In the penetrating wounds of the simple variety, there is no difficulty in making a diagnosis. The edges of the wound gape to a variable extent and the subcutaneous fat may prolapse. The amount of bleeding varies according to the vessels severed. If from an artery, it occurs intermittently and is bright red in color. If from a vein, the flow is continuous and of a darker color. If from the capillaries, called par- enchymatous hemorrhage, it is steady in character, but the amount is not so great as is that from an artery or vein. All the penetrating wounds of the skin may be associated with more or less contusion, i. e., laceration of the soft parts with hemorrhage into them, or the latter condition, known as a contusion, may exist without any such penetrating wound. A simple contusion causes a painful sweUing of the skin which may either be quite circumscribed or occupy a considerable area. Dis- coloration of the skin often occurs at a very early period, or may not appear until after some days, the skin becoming at first bluish, then yellowish in color. Both penetrating and non-penetrating wounds of the skin may be compHcated in the following ways : {a) There may be an associated injury of the other structures in the hmb. (6) The injury may be complicated by symptoms of shock or of general anemia from hemor- rhage, (c) One of the so-called accidental wound infections or other sequelae may be complicating the chnical picture. Signs of Injury of Other Soft Parts. — These may often be ascer- tained by inspection of the wound. In some it will be necessary either to retract the edges or to secure the information through {a) the discovery of loss of function of a muscle, tendon, or nerve; 424 THE EXTREMITIES. (b) through hemorrhage or gangrene resulting from injury of an artery or vein. If it becomes necessary to examine a wound the utmost precaution should be taken to prevent infection. In the majority of cases the loca- tion of the wound in relation to important anatomic structures and the obsen^ation of loss of function will suffice, so that a direct inspection of the wound is rarely necessary for diagnostic purposes. Fig. 258. — AIethod of Measuring the Forearm ix Order to Determine Atrophy of the Same. The patient may be examined while lying down. The point for measuring the circumference is at the level of the greatest amount of muscular development of the forearm. INJURIES OF MUSCLES. TENDONS, AND TENDON-SHEATHS. Contusions of Muscles. — A contusion of a muscle may be sus- pected if there is inability to use the muscle combined with locahzed tenderness and pain shortly after the injury. A little later, such muscular injury can be suspected if there is rapid atrophy, as determined either by palpation or by the measurement of the circumference of the hmb INJURIES OF MUSCLES, TENDONS, AND TENDON-SHEATHS. 42; and comparing it with that of the opposite one (Fig. 258). Such loss of function and atrophy of a muscle may be due to injury of the nerves supplying it or to non-use of the Hmb following bone or joint injuries. The latter are far more frequently followed by atrophy than is an ordinary contusion of a muscle. Fig. 25Q.— Method of Measuring the Circumference of the Arm Region Proper, in Okuer to Deter- mine Atrophy of Muscles. This may be performed either with the patient sitting up or lying down. In all of these measurements of the circumference of extremities one of the most accurate methods is to employ a steel tape-measure, and to take as the beginning-point some inch or centimeter measurement which is not too near the end of the tape, and to hold this point opposite some point to which the circumference of the arm may cause llic c.xammer to stretch the tape-measure. The second point is noted, and the distance of the beginning of the tape-measure to the starting-point subtracted from it. For example, if the starting-poinl chosen was the mark at the end of the one-inch measure, and the second point after the circumference had been measured was eight mches, the circumference of the arm would be the difference, or seven inches. Another sequel of a muscular contusion is the formation of bone in it, a condition known as Iraiimatic ossijyiug myosilis (myositis ossi- ficans traumatica). This condition of ossification between or within the muscles may follow cither repeated slight traumas or a single but severe one. 426 THE EXTREMITIES. The former are usually associated T\'ith certain occupations in which the muscles are subject to frequent injur}^, as the rider's bone in the adductor lon2;u3 muscle of cavaln' riders. In both varieties of cases there is to be felt in the muscles a hard bony mass whose formation can be directly traced to the trauma. The presence of the osseous deposit can be confirmed by an .v-ray exami- nation. Ruptures of Muscles and Tendons. — These may occur in any of the muscles or tendons of the ex- tremities, but are more frequent in cer- tain ones. Pure muscular ruptures occur oftenest in the biceps of the arm and in the quadriceps extensor of the thigh. Rupture of tendons occurs most fre- quently in the quadriceps extensor ten- don, either above or belovv- the patella. The tendo AcliilHs and the biceps bra- chii, either at its upper or lower ends, are next in frequency. These ruptures seldom occur as the result of external violence, but almost always from a violent contraction during unusual ex- ertions. These ruptures of muscles or ten- dons may be recognized from a sudden severe pain in the affected muscle or tendon, inabihty to use it, and the pal- pation of a gap at the point of rup- ture. In the case of muscular ruptures this gap or depression is marked on either side by a prominence formed by the torn ends of the maiscle. This gap is soon filled with a clot and becomes less prominent. In tendon rupture, especially of the lower end of the biceps, hga- mentum patellae, or of the tendo Achillis the gap is ver>' distinct and can be readily feh owing to the superficial positions of these tendons. Tendons may be pulled away from their points of origin or attach- ment by violence such as occurs when a hand or foot or the entire ex- tremitv is torn oft" from the remainder of the body. The tendo Achillis Fig. 260. — Flexion Contracture of All OF THE Fingers of the Hand. Caused by a crushing Lajury which opened up the flexor tendon-sheaths. INJURIES OF MUSCLES, TENDONS, AND TENDON-SHEATHS. 427 and ligamentum patellae are often torn from their respective attach- ments, by sudden and violent muscular movements. Dislocations of Tendons. — The only tendons which have so far been described as subject to this injury are those of the peroneal mus- cles and long head of the biceps. The condition can be recognized clinically if during contraction of the tendon the latter is felt as if springing out of its normal location. Fig. 261. — Direct Posterior View of a Case of Fig. 262. — Lateral View of Case of Olecranon Olecranon Bursitis. Bursitis. Note the swelling over the olecranon process. The white arrow points to the prominent olecranon bursa. Hernias of Muscles. — Either following severe contusions of the muscles with tears of the fasciae or after penetrating wounds of the latter, a localized swelling appears during contraction and vanishes during relaxation of the muscle. After disappearance of the swelling a distinct gap can be felt in the fascia through which the muscular hernia occurred. This injury is most apt to take place in the mus- cles of the thigh and leg and can be readily recognized. 428 THE EXTREMITIES. Penetrating Wounds of Muscles, Tendons, and Tendon- sheaths. — Penetrating wounds of muscles often occur as a part of complicated wounds of the skin, and can be readily recognized upon inspection of tlie cut edges or through loss of function of the muscles. If the wounds become infected, a purulent myositis may follow with sloughing of some of the muscle fibers. Tendon injuries occur oftenest on the anterior or posterior surfaces of the wrist or around the ankle and foot. The diagnosis may be made, either from inspection of the wound and observing the presence of the cut ends or by testing for loss of function in the corresponding parts, e. g., inability to flex or extend the fingers or toes. A partial severing of a tendon is of no significance unless the wound Fig. 263. — Bursitis of Metacarpo-phalangeal Bursa. B, Points to prominence due to bursa. is quite deep. Wounds of the hand in which the tendon-sheaths have been opened with or without laceration of the tendons are of great importance for two reasons: (a) the possibihty of infection spreading to the forearm; (b) the fact that the wound in the tendon-sheath is very prone to adhere to the skin wound, causing serious cicatricial defor- mities (Fig. 260). Injuries of the Bursae. — These may occur either in the form of contusions or of penetrating wounds. In contusions of the bursae there is rapid swelhng, local tenderness, and pain. Suppuration may take place without any communication with the overlying skin being present. Before infection has occurred, the diagnosis may be made by not- ing the presence of a painful swelling, which usually fluctuates dis- INJURIES OF BLOOD-VESSELS. 42Q tinctly, situated at the locations of the more superficial ]^bursae, viz., the olecranon (Fig. 261), metacarpophalangeal (Fig. 263), prepatel- lar, less often the subdeltoid, ischiadic, tendo Achillis, and trochan- teric bursce. Not infrequently the skin around the swelling shows evidences of extensive contu- ^ sion. If infection occurs after a contusion or a penetrating wound of a bursa, the swelhng becomes very tender, there is local redness, heat, and infiltration of the overlying skin, as well as the general signs of infection, such as elevation of temper- ature and pulse-rate, leukocytosis, etc. A knowledge of the location of the more common bursae is of great importance clinically (Fig. 265). Injuries of the deeper bursae, such as the subdeltoid, ilio- FiG. 264. — Dorsal View of Case shown in Fig. 263. (Lateral View), of Bursitis of the Metacarpo-phalangeal Bursa of Index-finger. psoas, or semimem- branous', may, if they suppurate, play a role in spreading the infection to the large joints with which they often communicate. INJURIES OF BLOOD-VESSELS. Injuries of Arteries. — These may occur in any of the arlrrics of the upper and lower extremities as llie result (a) of pendraling wounds with sharp instruments, such as a knife, razor, bayonet, etc. (b) In severe contusions of a limb, when an artery like the femoral or brachial is firmly compressed against the pubes or humerus respec- 43 o THE EXTREMITIES. tively. (c) As a complication of gunshot wounds or explosion of shells, etc. (d) In extensive crushing injuries of a hmb. (e) As the result of a simple or compound fracture, a fragment either pene- trating the vessel or the wall becoming necrotic from pressure of the displaced fragments upon it (Fig. 266). The diagnosis of an arterial injur}' is based upon (a) certain primary symptoms which im- mediately follow the injur}^; (b) other signs appearing at a later period, so-called secondary signs. The symptoms indicat- ing an arterial injur}^ which occur immediately depend upon Avhether the vessel has been completely or partially severed and whether the hemorrhage has ceased spontaneously. If one can observe the char- acteristic red spurting of an ar- terial hemorrhage, the diagnosis is easy. The cases are rarely seen at such a time, the bleed- ing, if it has been severe, either having caused speedy death or the extreme anemia occasioned by great loss of blood results in such slowing of the heart's ac- tion, that only a shght flow takes place from the end of the torn artery. The majority of cases are seen at a time when the hemor- rhage has been temporarily checked, either through the feeble action of the heart fol- lowing the severe loss of blood or as a result of a plugging of the tear in the artery by a thrombus or retraction of the vessel. If a large wound exists in which the torn vessel can be seen, the diagnosis is also easilv made. Fig. 265. — Location of Various Burs-e. I, Subdeltoid; 2, olecranon; 3, trochanteric; 4, isch- ial; 5, bursa beneath tendo AchilUs at its insertion in the OS calcis. INJURIES OF BOOOD-VESSELS. 431 Usually a diagnosis depends upon the recognition of other pri- mary and secondary signs. The remaining primary signs are: (a) the absence of a pulse in the peripheral vessels of the cold and pale limb; (&) the presence of a rough rasping murmur, synchronous with the pulse and resulting from the projection of a thrombus into the lumen; (c) the appearance of a large hematoma in the neighborhood of the injured vessel accompanied by signs of severe anemia. The so-called secondary or late evidences of an arterial injury are the appearance (a) of a traumatic or false aneurysm; (&) of beginning gangrene of the limb; (c) the occurrence of severe secondary hemor- rhage, usually about the sixth to ninth day. Traumatic or jalse aneurysms are more apt to follow stab than gun- FiG. 266. — -Sdpracondyloid Fracture of Femur. The illustration shows how the gastrocnemius muscle, whose action is represented by the black arrow, ter- minating at the letter G, causes the lower fragment to be pulled downward and backward, impinging upon the pophteal artery and vein, and resulting in gangrene of the leg in some instances. shot wounds. Clinically they can be recognized by the appearance of a swelling in the vicinity of the original wound or proximal to it (Fig. 267), which shows a distinct expansile thrill and a blowing, often rough, systolic murmur. At a later period, varicosities of the super- ficial veins become very marked. If both artery and vein are injured simultaneously, and this is not -infrequent, the symptoms in the early period do not differ, as a rule, from those of injury of the artery alone, except by an increased amount of edema of the limb. Later on, this swelling becomes quite marked and is accompanied by other signs, such as a continuous murmur, which is transmitted in a proximal and distal direction in both artery and vein. There is frequently also distinct venous pulsation and the veins become varicose (Fig. 199). The arteries most often injured are the subclavian, axillary, bra- 432 THE EXTREMITIES. chial, and radial in the upper, and tlie femoral and popliteal in the lower extremity. Injuries of the Veins. — With the exception of injuries of the larger venous trunks, these are of less importance and are rarer than the same conditions in the arteries. As in the case of the latter, the diagnosis may be made from certain primary or immediate and secon- dary or late signs. They may occur as the result of the same causes which were mentioned as producing arterial injury. In addition, the veins are often wounded during operations for the removal of tumors or en- larged lymph-nodes, and rarely during the perform- ance of a herniotomy. The larger trunks most often in- jured are the subclavian, axillary, brachial, femoral, and pophteal. The primary signs of vein injury are: (a) Hemorrhage, Avhich is seldom as great as after in- jury of the corresponding artery, but may be quite severe; it increases when the limb is held do vtl . The blood is of a dark color and flows in a steady stream. {h) The entrance of air in- to the vessels. This rarely occurs in wounds of the veins of the extremities. The late or secondary signs are (a) the formation of an arteriovenous or {b) of a varicose aneurysm, if the artery is simul- taneously injured (page 433). These are usually the resuh of stab and gunshot wounds and only occur in the larger vessels of the extremities. The symptoms of arteriovenous aneurysms vary somewhat accord- ing to the relations of the two vessels. I. If there is a wide communication of an arterial aneurysm with the vein, the pulse is transmitted to the latter, gradually decreasing in intensity from the point of contact in both directions. In addition Fig. 267. — Anterior View of Patient with Traumatic Aneurysm of Femoral Artery and Secondary Aneur- ysm OF External Iliac Artery. (i) The black semicircle below this figure indicates the size of the iliac aneurysmal sac as palpated through the abdom- inal wall; (2) extent of sac of aneurysm in femoral artery; (3) wound of entrance of knife. INJURIES OF THE NERVES. 433 to the systolic arterial, there is a continuous rough, sawing, venous murmur, often more marked during the diastole. 2. In an aneurysmal varix compression of the artery above the communication causes the sac to disappear, which is not the case in the first named variety. There is considerable edema of the limb and marked varicosities. 3. If there is a direct narrow communication, between the artery and vein, the only sign is a continuous rasping murmur transmitted along the vein, which ceases when the artery is compressed. Before leaving the diagnosis of vessel injury, it is desirable to refer briefly to the fact that apparently insignificant wounds, wherever sit- uated, in the body of a class of persons suffering from a condition knowTi as hemophilia, may bleed profusely and most persistently. This complication must always be borne in mind in cases of obstinate hem- orrhage from comparatively insignificant wounds. In addition to such unusual hemorrhage from wounds, whether operative or accidental, these individuals often have other symptoms of diagnostic value. These latter are: {a) The occurrence of purpuric spots, petechise, or ecchymoses into, or of hematomata beneath the skin, {h) Hemorrhages from various mucous cavities, Hke the stomach or intestine, (c) The occurrence of multiple joint swelling as described on page 624. INJURIES OF THE NERVES. These may be partial or complete. The former are called con- tusions and the latter lacerations or solution of continuity. The nerves of the extremities belong to the class of mixed motor and sensory nerves, hence any injury will cause a disturbance of their function which varies according to the degree of the injury. The diagnosis may, in general, be made from the following specific signs : 1. Paresis or paralysis of the muscles supplied by the injured nerve or nerves. The paresis or paralysis will be either complete or incom- plete, depending upon whether the affected muscle or muscles are sup- plied by the injured nerve alone or by several nerves. 2. Disturbances of sensation. There may be simple paresthesia or complete anesthesia. If the latter exists, the area will seldom cor- respond exactly to the normal cutaneous area supplied by the nerve. This is due to the fact that the anastomosis of the nerves of the skin is so free that, within a short period, the neighboring filaments often 28 434 THE EXTREMITIES. assume the function of the sensory endings of the injured nerve. Com- plete anesthesia usually follows the injury of several nerves of an ex- tremity. In addition to the disturbances of tactile sense, there is often severe pain along the course of the nerve. This is most frequently the case in those nerves which are gradually compressed, as by a callus or by the end of a dislocated bone. The appearance of pain usually indi- cates an incomplete solution of continuity. It has been frequently shown that compression of mixed sensory and motor nerves first causes disturbances of the tactile sense and ability to recognize cold, while at a later period there is absence of heat sensation and the appearance of pain. 3. Vasomotor and trophic changes. The former causes redness and local rise in temperature, which are followed gradually by cyano- sis and coldness of the limb. The trophic changes are usually most marked in the skin, rarely in the bones and joints unless the injury occurs early in life. The skin becomes smooth and shining, loses its elasticity, and deep ulcerations may occur. There is marked atrophy of the muscles and the joints become stiff and painful. 4. Changes in electrical reaction. In mild forms of contusion due to compression of the nerve there is seldom any change. Even though the paralysis be a complete one, after a contusion there may be no change in the electrical reaction. If, however, the nerve is completely severed, the response of the nerve toward both faradic and galvanic stimulation begins to sink about the second day, and ceases completely by the end of the second week. The affected muscles also fail to respond to the faradic cur- rent, but show an increased irritability toward the galvanic. These changes may persist for some time after the muscles begin to respond to voluntary impulses. 5. The appearance of a tumor at the seat of injury. In some cases neuromata develop at the point where the nerve has been either con- tused or severed. A spindle-shaped enlargement can often be felt at the point where the nerve has been injured or cut, after a variable period, usually two to three months. In some cases, as in amputa- tion stumps, it may be excjuisitely tender to the touch. Injuries of the nerves occur as the result either of pressure or of laceration of the nerve. The former may (a) immediately follow a single trauma, like a blow or a kick or the apphcatibn of a constrictor; (b) it may follow the pressure of crutches (crutch paralysis) ; (c) the nerve may become compressed between the fragments of a fracture or by INJURIES OF THE INDIVIDUAL NERVES. 435 a callus (Fig. 268). Lacerations of nerves follow (a) gunshot, stab, or any variety of wound made by cutting or tearing violence; (b) penetration by a fragment of bone in fractures; (c) crushing of the nerve without an external wound. INJURIES OF THE INDIVIDUAL NERVES. The circumflex nerve is most frequently injured in connection with fracture of the surgical neck of the humerus. It may also be injured in dislocations of the shoulder as well as in severe sprains, without fracture. The prin- cipal symptom is paralysis of the deltoid resulting in inabil- ity to raise the arm from the chest and in such marked atro- phy that the normal con\'ex outline of the shoulder is lost. The musculospiral nerve is more often injured than any other in the body. In the ax- illa it may be compressed by the head in dislocations of the humerus or by the pressure of a crutch. At the middle of the shaft (Fig. 268) it may be compressed by too tight an ap- plication of a constrictor, or more often by being caught in a callus in fractures at this level. It may be torn by blows over this place without any wound of the skin. Its' continuation, the radial nerve, is often severed in gunshot wounds of the forearm or in incised wounds just above the wrist. The motor symptoms vary somewhat according to the level of the injury: (a) If in the axilla, the elbow, wrist, and fingers cannot be extended, (b) If at the middle of the humerus, the elbow can be ex- tended but there is inabihty to supinate the forearm and to ilex it, when Fig. 268. — Musculospiral Nerve Compressed ^y a Callus Resulting prom a Fracture in Middle of Shaft of Humerus (Lejars). MS, Musculospiral nerve above and below point of com- pression by callus. 436 THE EXTREMITIES. half-way between supination and pronation (supinator longus action). There is, in addition, the loss of movements of extension of the fin- gers and wrist, (c) If below the humerus, the elbow can be extended Fig. 269. — Wrist-drop. Due to pressure paralysis of the musculospiral nerve, following too tight an appUcation of an Esmarch ^:?*'- FiG. 270. — Claw-hand (Main en griffe) Following Ulnar Paralysis (Leube). and forearm supinated, but the inabihty to extend the wrist and fin- gers is more prominent (Fig. 269), causing the deformity known as wrist-drop. The sensory symptoms are often so shght as to escape nodce at INJURIES OF THE INDIVIDUAL NERVES. 437 first, because the median and ulnar nerves establish a collateral supply. When anesthesia is present it is most marked over the back of the thumb and index- finger. The ulnar nerve is injured either in gunshot or stab wounds of the forearm or in incised wounds just above the wrist. The motor symptoms are inability to flex the first and to extend the second and third phalanges of the fingers, resulting in a claw-hke deformity (Fig. 270). The thumb cannot be adducted nor can the wrist be drawn toward the ulnar side. As a rule, there is anes- thesia only over the little finger. The median nerve is most often injured in the same manner as the ulnar. The motor symptoms are inability to flex the fingers except the ring and little fin- gers. The first phal- anges of the fingers can- not be flexed on account of paralysis of the in- terossei muscles. The thumb cannot be flexed or abducted. The area of anesthesia is usually very small and most marked over the volar surfaces of the thumb, index, and middle fin- gers. The brachial plexus may be injured (a) through tearing of one of the nerve- roots close to its emergence from the spinal cord. These are kno^^^l. as birth paralyses.' The most frequent type is that known as the Duchenne (Fig. 271). (b) In the axilla, as the result of disloca- tions or gunshot wounds, (c) In fractures and other injuries of the upper arm or forearm regions, several of the nerves of the plexus may be involved simultaneously. Of chief interest is the first named mode of injury, viz., traction on the arm during ]:>irlh. It may rcsuh in a subluxation of the humerus simulating a true dislocation. There is Fig. 271. — Duchenne Paralysis. Due to tearing of the fifth and sixth cervical nerves during birth, close to their point of emergence from the spinal cord. (See text.) The position of the hand is typical. 438 THE EXTREMITIES. inability to raise the arm and to supinate the forearm, the latter being held pronated with a drop-wrist deformity. The sciatic nerve and its branches are oftenest injured in the lower extremity. The main trunk may be severed by gunshot or stab wounds of the thigh. It is rarely caught by a callus or compressed by fragments at the time of injury, in supracondyloid fractures of the femur. Injuries of the main sciatic trunk are quite rare. They result in the absence of ability to use any of the muscles below the knee as well as inability to flex the knee-joint. There is anesthesia over a narrow strip from the gluteal fold to the calf of the leg, which then spreads so as to em- brace all of the leg and foot except an area along the inner side supplied by the internal saphenous. The external popliteal or peroneal nerve has been caught in a callus in fractures of the upper end of the fibula. Injury of this branch re- sults in inability to raise the outer edge of the foot (paralysis of peronei), to extend the toes, or to flex the ankle. There is an area of anesthesia over the outer half of the front of the les; and dorsum of the foot. GENERAL CONSIDERATIONS OF INJURIES OF THE BONES. Injuries of the bones and joints of the extremities are so often associated that they will be considered together. Before taking up the diagnosis of injuries of the individual bones and joints, a short review of their more general characteristics will be of value. These are, as a rule, of two varieties: (a) contusions; (b) fractures. Contusions of the Bones. — These are the result of direct violence and affect the periosteum. For this reason the condition is often spoken of as a traumatic periostitis. The periosteum becomes greatly thickened and very tender. The diagnosis can readily be made by palpation in the more superficial bones like the tibia, where it most frequently occurs. At times the swelling in the periosteum becomes quite locahzed and fluctuates as the result of the liquefaction of a hematoma. In some places, like the neck of the femur, a contusion of the bone may be fol- lowed by softening and bending of the bone. (See Coxa Vara Trauma- tica.) The periosteum remains thickened for some time and then grad- ually resumes its normal size. Fractures. — These are divided according to various criteria: (a) Into incomplete and complete, according to whether or not the line of fractures passes partly or entirely through the bone, (b) Into those which occur in a normal bone or in one changed in its structure as the result of disease (pathologic jractures). (c) Into those in which there GENERAL CONSIDERATIONS OF INJURIES OF BONES. 439 is no communication between the wound in the skin and the seat of fracture, called simple or closed jractures, and those in which there is such a communication, called compound or open jractures. A third class in this division are the fractures which are associated with injury of nerves, blood-vessels, etc., and called complicated fractures. A fourth class also belongs to this group, viz., the gunshot fractures. Incomplete fractures are subdivided as follows: (i) Fissured. (2) Greenstick or infraction (Fig. 272). (3) Depressions. (4) Separation of a splinter or apophysis. Complete fractures are subdivided according to the direction of the line of fracture into : Fig. 272. — Various Forms of Lines of Fracture. I, Complete transverse; 2, longitudinal; 3, oblique; 4, spiral; 5, incomplete or greenstick; 6, subperiosteal. 1. Transverse. These are rare in the shaft of the long bones and are usually found in the lower end of the radius, in the femur, and in the short bones. 2. Longitudinal. Only two cases have been reported of this form of fracture line. 3. Oblique. This is the most frequent form in the shaft, but occurs less often in the epiphysis. If in the latter portion of the bone, it is either confined to it alone or extends from it, into the shaft. 4. Spiral. This was formerly considered a rare form of fracture. With the more systematic use of the .\'-ray as a portion of the routine of diagnosis, they are found to occur far more frequently than was thoutrht to be the case. Thev are usuallv the result of a rotating or 440 THE EXTREMITIES. twisting force and occur oftenest in the femur, then in the tibia, humerus, and fibula. There is a great tendency in this variety to penetrate the skin. Number of Fragments. — In the majority of fractures there are only two fragments. In many, however, the bone is broken in such a manner that there are three or more fragments. If each of the latter are large, the fracture is called a multiple one; but if they are quite small, as after a crushing force, the fracture is termed a comminuted one (Fig. 340) . The lines of fracture may resemble a letter Y or T, and this variety is especially apt to occur at the epiphyseal ends of certain bones, like the humerus. Displacement of Fragments. — This either occurs at the time of the Fig. 273. — Various Forms of Displacement or Fragments in Fractures. I, Lateral; 2, angular; 3, overriding; 4, axio-rotation; 5, overlapping and angular combined; 6, great separa- tion of fragments. accident or as a result of the weight of the hmb or the action of muscles at a later period. The various forms are: (a) Dislocatio ad axin or angular deformity. This seldom occurs alone, but usually in conjunc- tion with one or all of the other varieties, (b) Dislocatio ad latus or lateral or side-to-side displacement (Fig. 273). This rarely occurs in a pure form except in transverse fracture, (c) Dislocatio ad longitudi- nem or overlapping or overriding of fragments. This form is one of the most frequent results of oblique fractures, (d) Dislocatio ad axin or rotary deformity. In this variety the surfaces of the bone (Fig. 273) which are normally in apposition have rotated upon each other. Seat of Fracture. ^A fracture may (a) involve the diaphysis or shaft of a long bone, or (&) the epiphysis, or (c) occur through the epi- physeal cartilage (epiphyseal separation), or (Ian of THiRTy-Fi\'E. The outlines of the Kne of fracture were traced in ink upon the x-Ta.y. The shaft of the bone has become impacted into the head. The patient often experiences a sensation as though sometliing moved in the joint or snapped back with a distinct cHck. Some patients observe a prominence on the inner or outer sides of the joints. If the attacks recur frequently they are milder than if far apart. In the latter there is usually more or less effusion present. The patients can often reduce the luxation by traction on the leg and by rotation. GENERAL CONSIDERATIONS UPON INJURIES OF JOINTS. 455 Vollbrecht ^ has described two groups of cases. In the first the original injury is f oho wed, after a long confinement to bed, by the typical attacks, which are almost continuous. In the second group there is an apparent recovery from the first ac- cident after a tedious convalescence. After a second or third trauma the typical clinical picture sets in. One of the most characteristic objective signs is the interference with movements. Both flexion and extension are actively and passively interfered with. Another confirm- atory sign, if found, is the palpation of a movable body in the gap between the femur and tibia. There is also great ten- derness over the dislocated meniscus. (c) Free bodies in the joints. These have been variously termed floating cartilage, loose cartilage, joint mice, etc. They may result from the application of a direct (fall, blow, crush) or of indirect force (sudden tension of mus- cles or ligaments, torsion). They may occur even after very slight injury. They occur oftenest in the knee- joint, but may also follow injury to the shoulder, elbow, and wrist. The most characteris- tic symptom is the so-called "locking" of the joint, due to the fact that the foreign body becomes wedged between the articular surfaces. There is severe pain and the joint is' suddenly checked in its range of motion, so that flexion and extension cannot be executed. Such attacks may be accompanied by considerable effusion. Occasionally the free body can be felt and held between the fingers. After some manipulation the float- ing cartilage becomes free and the joint can be used again. The typical sym})toms may not ap])ear until some lime (months to ^Bruns: "Beitriigc zur klinisclicn Chirurgic," Bd. xxi. Fig. 288. — Posterior View of Subcoracoid Dislocation OF Shoulder-joint. Same case as shown in Fig. 289. N, Normal shoulder; D, dislocated shoulder. 456 THE EXTREMITIES. years) after the injury or they may become noticeable immediately after the initial symptoms have passed away. GENERAL CONSIDERATIONS UPON DISLOCATIONS. Dislocations are either (a) traumatic, (b) pathologic, or (c) congenital in origin. They may, as in the case of fractures, be either simple or compound, according to whether or not there is a communication be- tween a wound in the skin and the seat of injury. If a dislocation tend to recur from time to time after having been reduced, it is termed a recur- rent or habitual dislo- cation. If the dislocation has remained unre- duced for a long per- iod it is called an inveterate or ancient or unreduced disloca- tion. The pathologic dislocations are the result either of {a) an excessive distention of the capsule, (&) a malformation as the result of disease of the articular ends of the bones composing the joints. In both cases, following a slight trauma or independent of one, the dislocation occurs. These spontaneous or pathologic dislocations are described in the section on diseases of the joints. A dislocation may be complicated by injury of the soft parts or by a fracture involving the articular bone ends. Compound dislocations are much more apt to be complicated by injuries of vessels and nerves than the simple are. The recognition ofan injury to one of tJie blood-vessels of the limb Fig. 289. — Anterior View of Dislocation of Shoulder-joint. Same case as shown in Fig. 288. N, Normal shoulder. Note the absence of prominence of the acromion process, and the presence of the normal convexity of the shoulder. D, Dislocated shoulder. Note the prominence of the acromion process, and the flattening of the shoulder due to absence of the head of the humerus. GENERAL CONSIDERATIONS UPON DISLOCATIONS. 457 is difficult. Such a lesion, as a rule, occurs oftenest in dislocations of the shoulder and knee. The signs are: The pulsations of the artery below the point of impingement cannot be felt, the Hmb is cold, and pressure with the finger shows no varia- tion in color when the finger is raised, as in the case of a normal limb. Gangrene may occur immediately, i. e., within a few days or only grad- ually. If the artery has been torn a large pulsating swelhng rapidly forms accompanied by signs of shock and internal hemorrhage. AcP Fig. 290. — X-RAY OF Subcoracoid Dislocation of tbe Shoulder-joint. C, Coracoid process, below which lies the head of the humerus (HH); EGC, empty glenoid cavity; AcP, acromion process of scapula. Note the flattening of the shoulder below the acromion process due to the ab- sence of the head of the humerus. Injury 0} nerves as a result of dislocation is more frequent than is injury of the vessels. Rupture of a nerve is quite rare, while a contusion occurs not uncommonly. The diagnosis of nerve injury can be readily made from the presence of the disturbances of sensation and motion characteristic of such injury. In the upper extremity paralysis of the musculospiral nerve is far more frequent than is that of all the other nerves. In the lower extremity the sciatic and anterior crural are occasionally involved. 458 THE EXTREMITIES. Other complications of dislocations are: (a) injuries of the skin and other soft parts in compound dislocations; (b) the occurrence of atrophy of the muscles proximal and distal to the joint, as well as the formation of adhesions within the joint; (c) fractures involving the articular ends of the bones which enter into the formation of the joint. Diagnosis of Dislocations in General. — As in fractures, a diag- 5. Fig. 291. — Various Forms of Fractures of the Upper End of the Humerus Associated with Dis- location OF the Head of Humerus (Robert Jones). I, Split fracture of shaft of humerus with subcoracoid dislocation of head; 2, obUque fracture of upper end of humerus with subcoracoid dislocation and separation of greater tuberosity, 3, fracture cf surgical neck of humerus, with dislocation of head; 4, fracture of surgical neck of humerus with displacement upward of head, and inward of shaft; 5, subglenoid dislocation of humerus, with separation of greater tuberosity to outer side, and lesser to inner side; 6, subglenoid dislocation of humerus, with fracture of anatomic neck and separation of greater tuberosity. This illustration was made from skiagraphs. nosis can be made from certain objective and subjective signs taken in conjunction with an accurate history of the manner in which the accident occurred. The examination should be made by (a) inspecting the limb to as- certain the nature of the deformity; (b) palpating the parts to learn the relation of the displaced articular ends to each other; (c) measuring the GENERAL CONSIDERATIONS UPON DISLOCATIONS. 459 limb with the aid of certain fixed anatomic points (Fig. 283); {d) an .T-ray examination if necessary to confirm the diagnosis of dislocation and to ascertain whether there is a complication in the shape of a fracture. The objective signs of a dislocation are : I. Deformity. — The position in w^hich the hmb is held is often so characteristic that a simple inspection will indicate the condition to the experienced eye. In stout individuals such a change in the axis of a Fig. 292. — Lesions to be Considered in Differential Diagnosis of Shoulder Injuries. A, Acromion process of scapula; P, coracoid process of scapula; S, body of scapula; C, claN-icle; H, humerus; i, normal shoulder- joint, showing convexity due to presence of head of humerus in glenoid ca\Tty, and to deltoid muscle; 2, subcoracoid dislocation of the humerus; 3, fracture of surgical neck of humerus, dis- placement of lower fragment inward. Note the flattening of the normal convexity of the shoulder in both 2 and 3. 4, Fracture of neck of scapula, permitting humerus to drop; 5, upward dislocation of acromial end of clavicle; 6, fracture of clavicle, with typical displacement of fragments. limb or of its position is much more apt to l^e overlooked than in thinner individuals. In general, the deformity may be said to be due (a) to a change in the direction or axis (Fig. 288) of the dislocated bone or bones; (&) to the abnormal position as determined by palpation (unless too much swelling exists) of the dislocated articular ends; (c) to the presence of an empty joint socket. 460 THE EXTREMITIES. 2" ^ -^ JJ >, -2 ^- II P -0 u ^ d 6 d g iH a !-l 'Sh-S 1: 0^ c c 3 ^ c 3 y , , ^ -^ 4:, c > c d, ge and a in a n chil ductio ly mc broke ^ c« >^:" -T3 C CO p .ti "^ rt 0.2i e^-a:s^ T3 « Jess in- net ere lal mo ess ma ad fixe ossible tuberc C-^ -tiyA =J C1.-S p ^1 T3 o < P4 p< lU rQ ;y a. M-H Tl cd X) n -;5 K c made from the following data: 1. They occur at the epi|)hyseal ends of the most rapidly growing bones (femur, tibia, and lumurus) of young adults. Only 5 per cent, occur beyond the age of forty. 2. In the periosteal form a palpable enlargement of the bone appears quite early, and is soft unless ossification lias occurred. 3. In the medullary form the patient complains for some time of pain over the end of one of the above-mentioned long bones. After 6oo THE EXTREMITIES. Cancellous tissue with red mar- row a variable period a swelling appears at the seat of pain, and may be hard or soft, according to the amount of osseous tissue. 4. Trauma in young adults, followed by pain and tenderness which do not disappear within a month, should be watched as indi- cating the possibility of development of sarcoma. 5. A rise of temperature, and effusion into the adjacent joint is not uncommon, especially in the periosteal form. 6. The growth of bone sarcomata varies greatly. In the giant- celled and in the osteosarcomata it is very slow. In the other varieties it is more rapid and progressive than that of any other form of bone neoplasm. 7. The x-rsLj is of value in distin- guishing bone neoplasms from inflamma- tory processes or trophic changes. It may be said that the more cellular types, like the periosteal and the small rounded myelogenous sarcoma, generally show a translucency or faint shadow (Fig. 407) wherever the bone has been involved. The ossifying periosteal and myeloge- nous sarcomata give the most typical pictures. In the former (periosteal osteo- sarcoma) the tine spicules of bone are shown radiating from the periosteum. In the central or myelogenous osteosarcomata the .-v-ray shows a deep shadow with irregular margins throughout the extent of the growth, thus differing from the soft myelogenous forms which show a faint shadow. 8. Spontaneous fracture is a valuable sign in both the benign (osseous cysts) and malignant types of bone neoplasms. It may be the first symptom on account of which the patient consults the physician. 9. In some osteosarcomata with large vascular spaces pulsation is so marked as to simulate an aneurysm. In the differential diagnosis of osteosarcomata one must consider (a) tuberculosis of bone, (b) chronic abscess resulting from a former acute osteomyelitis, (c) simple or benign osseous cysts, (d) other forms of malignant bone neoplasms, such as myelomata, peri- and endothehomata, and secondary carcinomata. Fig. 410. — Sectional View of Ossi- fying Periosteal Sarcoma of THE Tibia in a Girl (J. Bland- Sutton). DISEASES OF THE JOINTS IN GENERAL. 6oi The chief differential points of the first three were enumerated under simple bone cysts. The other forms of malignant neoplasms can only be differentiated from sarcoma by a consideration of the history of the case and the age of the patient. Carcinomata are always secondare' to a primar}^ growth in the thyroid, prostate, or breast, and occur at a late period of life. Endo- and peritheliomata of bone occur after forty, as a rule, but do not differ clinically in other respects from the ordinary- forms of sarcomata. Myelomata cannot be differentiated from sarcomata clinically. Other Forms of Malignant Bone Neoplasms. — In considering the diagnosis of the nature of a malignant bone neoplasm one must not omit the following forms: 1. Carcinoma. — This usually occurs as a metastasis of a primary carcinoma of the breast, prostate, or thyroid. It occurs most fre- quently in the femur, and the primary tumor may have been over- looked until a spontaneous fracture occurs. 2. Myelomata are composed of tissue which is similar to that of the red marrow of young bone. The tumor arises in the medulla of the bone, and on section looks like a freshly cut liver. It occurs oftenest in the tibia. Quite rarely the tumor is found in the lower end of the radius and ulna, upper end of the fibula and humerus, and lower end of the femur. The patients are young adults. The growth of the tumor and expansion of the bone take place very slowly, so that they behave more like the giant-celled central sarcomata. Endo- and Peritheliomata of Bone. — About twenty-three cases^ have been reported of this form of bone tumor, which can only be distinguished clinically from osteosarcoma by the fact that o\-cr seventy-three per cent, occur after the age of forty, while sarcoma is rare at that period of life. DISEASES OF TKE JOINTS IN GENERAL. When the surgeon or ])hysician is consuhcd b\- a paticiit suffering from some joint affection, the first question he asks liimsrU" is, What is the nature 1 the condition^ In order lo \k' able to systematically exclude one etiologic factor after the other, it is necessary to have some classification of joint diseases whicli sliall serve as a working basis. In the light of our present knowledge tlie most satisfactory division is into two great clinical groups, the acute and chronic. It is necessary, ' Howard and Crilc: "Annals of Surgery," Sept., 1905. 6o2 THE EXTREMITIES. however, to state that there is often no hard and fast Hne between these two, since affections placed under one head will often present them- selves clinically in such a form as to make it seem more appropriate to place them under the other. Until the etiology and pathology of chronic articular rheumatism and arthritis deformans is thoroughly investigated, no large grouping for these two affections will seem ap- propriate. They are undoubtedly of infectious origin, but the exact nature of the latter is as yet undetermined. A classification which will be found most useful from a diagnostic point of view is that suggested by Konig. The general term "arthritis" is used in preference to that of syno- vitis for some affections. Clinically the distinction cannot always be made between a case of synovitis and one of arthritis, since the same affection may at one time involve only the synovial membrane and, at another, all of the structures of the joint. The classification is as follows: Acute Arthritis. I. Primary acute arthritis. 1. Acute traumatic. 2. Acute articular rheumatism. 3. Acute gout (described under gout). II. Secondary acute arthritis. A. Metastatic arthritis. 1. Through ordinary pus cocci, pye- mic arthritis. 2. Through other specific microor- ganisms, (a) Typhoidal arthritis. (&) Pneumococcus arthritis. Influenzal arthritis. {d) Scarlatinal arthritis, (e) Gonorrheal arthritis. (/) Syphilitic arthritis (secon- dary stage). Secondary acute arthritis by exten- sion. 1 . From an osteomyelitic focus (acute arthritis of infants) . 2. From the surrounding soft tissues (erysipelas, phlegmon, bursitis, tendo-vaginitis and lymphan- gitis). Chronic Arthritis. I. Tuberculosis. 1. Primary osteal. 2. Primary synovial. II. Chronic serous synovitis. (Chronic articular synovitis.) III. Arthritis deformans. IV. Chronic articular rheumatism. V. Chronic and atypical gouty arthritis. VI. Syphilitic arthritis. VII. Neuropathic arthritis. (a) Tabes. (b) Syringomyelia. VIII. Hemophiliac and scorbutic arthritis. IX. Tumors of joints. X. Hysterical joints. In attempting to make a diagnosis of a joint affection, it is neces- sary to keep some such classification constantly in mind. DISEASES OF THE JOINTS IN GENERAL. 603 The examination should embrace the following: 1. An accurate history of the duration and mode of onset. 2. The general condition of the patient. 3. The examination of the affected joint or joints. I. History of the Case. — If carefully taken this will yield much in- formation as to (0) the mode of onset, whether sudden or gradual; (h) its relation to an injury either recent or at some remote period; (c) whether the affection accom- panied some one of the systemic infections just mentioned; {d) whether it appeared after symp- toms of a local infection had existed; {e) the family and per- sonal history, as to hereditary or acquired diseases, habits, hemo- phiha, etc. 2. The General Condition of the Patient. — This embraces a thorough examination of the entire body, including tempera- ture, pulse, condition of lungs, heart, and other viscera, and of the nervous system. Without such a general survey a case of tabetic joint, for example, may be easily overlooked. Again, the coexistence of tuberculous foci elsewhere will often throw great hght on the nature of an obscure chronic joint affection. Evi- dence of cardiac or other serous fig. 411 -—f-xti-knai-Vikw of patient with piri- . , . • r 4. OSTEAL Sarcoma of Upper End of Fibula. membrane mvolvement is of great ^^^^ ^^^^^^ ^^.^^^ ^^ ^^^ ^^^^^,^ ^^,^^^^^ ^^^^^ .,^^_,^^ value in the diagnosis of rlieuma- region, tic affections. x\t times a therapeutic test is necessary, in onkT to dear u]) a diag- nosis of rheumatism or syphilis. 3. Examination of the Joint.— (a) Inspection reveals llic presence or absence of swelling, deformity, redness, cck^ma of the ()\erlyingskin, etc., in the more superficial joints. (b) Palpation shows the presence or ab.sence of lluctuation, of locahzed or general tenderness, and of the degree of li.xationof the joint. i 6o4 THE EXTREMITIES. (c) Exploratory puncture. This is a very valuable aid in ascer- taining the character of the fluid, and must be performed with every possible regard for asepsis (see Fig. 412). (d) X-ray. This gives much information in regard to the con- dition of the articular ends of the bones entering into the joint forma- tion. In acute cases it is of httle value; in chronic cases the changes are often slight or appear very late, especially in tuberculosis. (e) Mensuration. The measurement of a joint and the com- parison of the result obtained Avith that of the corresponding joints of the opposite limb is of great value in confirming other data. The chief diagnostic features of the principal joint affections are as follows : Acute Traumatic Arthritis. This may follow (a) a blow over a joint or a fall upon a joint; (b) a distortion or twisting; (c) it may accompany a dislocation and, finallv, (d) it occurs as the result of a fracture into the joint or in close prox- imity to it. The history' is usually quite clear. The injur}- is followed by severe pain over the joint and by loss of function. Within a few hours there is noticeable swelhng of the joint. It loses its normal con- tour, all of the depressions over it being eftaced by the rapidly increas- ing swelhng. Exploratory puncture is rarely necessary for diagnostic purposes. If performed, however, the exudate will be found to be a clear, straw- colored fluid containing much albumin, more or less fibrin, and a few leukocytes. As a rule, fever is not a diagnostic sign in an acute traumatic ar- thritis. There is, however, a rare possibility of a pyogenic infec- tion of hematogenous origin, which will change the clinical picture. Under these latter circumstances the pain and swelling will be exces- sive. The presence of such increased local signs, accompanied by constantly increasing leukocytosis and fever, will speak for a joint infection. Another fact is also of value from a diagnostic point of view. A joint trauma may be followed by an acute gonorrheal arthritis in a patient sufl'ering from a subacute gonorrheal urethritis. Such a case is not readily recognized unless it be borne in mind that infection of a traumatic arthritis is very rare. If fever and other signs occur in such a joint, a search should be made for primary foci of pus infec- tion, such as the urethra, etc. Acute traumatic arthritis is also of interest on account of its sequelae. DISEASES OF THE JOINTS IN GENERAL. 605 It usually disappears gradually, but may become chronic. The effu- sion either remains, or it disappears and then recurs from time to time. In the former case the disease is termed a chronic serous synovitis (see page 614). In the latter, i. e., when it recurs, it is often given the special name intermittent articular hydrops (see page 614). Among the other sequelae of an acute traumatic arthritis or sprain of a joint, may be mentioned a subluxation of the articular cartilage, the formation of free or floating bodies,^ and finally the development of tuberculous foci in the joint itself or in the epiphyseal ends of the long bones in close proximity to it. Acute Articular Rheumatism. This form of joint affection is usually polyarticular, but it may appear in one joint and follow a trauma. Under the latter conditions the clinical signs may be almost identical with that of a sprain. The question can seldom be decided, without observing the rapid improvement following antirheumatic treatment (saHcylates, etc.). Local examination of a rheumatic joint of the monarticular type also shows greater tenderness over the affected joint, frequently ac- companied by some degree of fever. If polyarticular the diagnosis is not difficult in the more acute forms. The joints are greatly swollen, there being considerable edema of the periarticular tissues. There is also a variable degree of fever, usually from 101° to 104° F. The joint symptoms are frequently accompanied by sweats and evidences of involvement of the serous membranes, especially of the heart. The disease is also characterized by its tendency to wander from one joint to the other. The greatest difficulty in both the monarticular and polyarticular forms is to differentiate them from the other varieties of multiple joint infection. The latter are, as a rule, secondary to foci elsewhere, whereas in an acute rheumatism such primary foci cannot be found. The rnost frequent source of difficulty is to differentiate multiple gonorrheal joint invasion from that of an acute rheumatic form. Another form of arthritis which may simulate the acute rheumatic form is that resulting from an osteomyelitic focus of suppuration in the epiphyseal ends of the long bones, such as the femur or tibia. In the more superficial joints, like the knee or shoulder, the more severe local signs, such as pain, tenderness, etc., will enable one to differen- tiate this form of acute arthritis. In deeply situated joints, like ' For a description of the diagnosis of these complications see Injuries of Joints on page 6o6 THE EXTREMITIES. the hip, the diagnosis is more difficult. This form of acute septic arthritis occurs chiefly in children, and is accompanied by far more grave symptoms of infection than is the case in an acute articular rheu- matism. In infants such an acute osteomyelitis of the hip with secondan^ arthritis causes high fever, severe pain on movement of the limb, flex- ion, and early abscess formation. In older children there is also high fever, leukocytosis, delirium, much swelling, and marked local joint S}Tnptoms. The presence of these localizing signs, the invasion of a single joint, and the more severe constitutional symptoms enable a dift'erential diagnosis from an acute rheumatism to be made. The differentiation of gout, acute arthritis deformans, and acute forms of tuberculous arthritis will be considered under the respective heads. Secondary Acute Arthritis. As was stated above, a primary purulent arthritis is very rare. Usu- ally such an acute infectious joint disease is secondar}- to a more or less distinct primary focus. It is of the utmost importance to recognize this fact when called upon to make a diagnosis of an acute arthritis. It is not always easy to state definitely the exact nature of the process. 1. The histor}^ should be carefully taken to ascertain (a) whether the joint affection followed one of the acute infectious diseases to be mentioned below; (b) whether it was preceded by an acute or a subacute gonorrheal process; (c) w^hether it foUoAved a pyemia, and, finally, (d) whether it was preceded by CAidences of infection in the bones forming the joint or in the soft tissues around it. 2. The examination of the exudate should be regarded as a more or less routine procedure in the diagnosis of this class of joint afl'ections. This is conducted by aspirating (Fig. 412) some of the eft'usion and examining it cytologically, as well as staining it for microorganisms and inoculating culture-media from it. The exudate may often be sterile, or the organisms can only be demonstrated after repeated examinations. The acute arthritis of this group may be secondary to one of the following : 1. To a pyemia or septicopyemia — staphylococcus aureus and streptococcus pyogenes infection. 2. To one of the acute infectious diseases — typhoid, pneumonia, influenza, scarlatina, gonorrhea. With the exception of scarlatina, the specific organisms of the respective diseases can be found. DISEASES OF THE JOINTS IN GENERAL. 607 3. Secondar}" to an acute osteomyelitic focus or to infection in the soft parts. Ordinary pus cocci, unless the primary disease has been caused by other organisms, are usually found. The clinical characteristics common to the majority of these cases of secondary acute infectious arthritis, are marked swelling, tender- ness on palpation, pain on motion, loss of function, a variable degree of fever, leukocytosis, and more or less constitutional disturbances. The disease may affect a single joint or be polyarticular. The joints involved are seldom as exquisitely painful ; there is also less tendency to a shifting about from one joint to another, and there is a higher degree of leukocvtosis than in acute articular rheumatism. .>A Fig. 412. — Method of Performing Exploratory Puncture of the Knee-joint. The point of election is one situated to either side of the patella, preferably the outer, e. g., point indicated in the illustration by the cross. The needle is inserted beneath the patella, which has been raised up by the fluid, and the piston gradually withdrawn. Several of these forms of acute secondary arthritis require special mention. Arthritis Secondary to Pus Foci Elsewhere (Pyemic). — This form occurs during the course of a general infection with the ordinary pyogenic organisms, viz., the staphylococcus aureus and the strep- tococcus pyogenes. When the joint affection is the direct result of a well-pronounced pyemia or septicopyemia it presents but little diffi- culty in diagnosis. The cases, however, in which the primarv lesion was a furuncle or some other comparatively insignificant focus, such as a tonsilhtis, otitis, etc., present far more difficulty. The exudate is always purulent, and contains the organisms which have caused the 6o8 THE EXTREMITIES. priman' disease. Usually the disease is monarticular, the joint being greatly swollen and very painful. The local disease is accompanied by high fever and other septic symptoms. The periarticular edema is ver}' marked, and perforation of the capsule, followed by extensive necrosis of the joint cartilage, occurs at an early stage. Typhoidal Arthritis. — This is an infrequent complication of typhoid fever. The infection is seldom due to the specific bacillus alone. In the majority of cases it is a mixed infection, i. e., in associa- tion w^ith the ordinar}' pus cocci and the colon bacillus. The joint complications occur usually during convalescence, or even months or years after the attack of fever. If it occur during convalescence the general symptoms are prolonged, and there is more or less fever. The local s}Tnptoms are not very severe, the pain, swelling, and ten- derness not being marked. The exudate may contain the typhoid bacillus alone. In the ma- jority of cases the specific organism is mixed with staphylococci or colon bacilli. That which has been previously stated as true of all of the arthritides of secondary origin is true of this form, viz., that the joint exudate may be found sterile. The exudate can be either serous or pur- ulent, and the. disease may affect only one or several joints. Pneumococcus Arthritis. — This form of arthritis may occur (a) as a direct compKcation of a pneumonia; (b) as a metastasis of a pneu- mococcus septicemia, or (c) as a purely local disease ^dthout any pre- ceding pneumonia or any septic symptoms. When the arthritis occurs as a complication of pneumonia it usually appears during the period of convalescence. The joint symptoms are quite marked. The pain varies in severity from a slight to a ver}' severe one. Tenderness and swelhng of the joint are very pronounced. Red- ness and widespread edema indicate an involvement of the periarticular tissues, and in some cases quoted by Herrick ^ an abscess was found in the structures about the articulation. The lesion is usually monarticular, the knee-joint being most often involved. Exploratory aspiration of the joint effusion with bacteriolo- gic examination of the fluid is the only means of recognizing the pneu- mococcic character of the disease. It must not be forgotten that an arthritis following a pneumonia, may be due to the ordinary pus cocci. The joint fluid may also be sterile at the time of the examination, so that repeated punctures should be made. . The constitutional symptoms show great variations (Herrick). In some cases the joint symptoms are insignificant as compared with those ' "American Journal of Medical Sciences," 1902. DISEASES OF THE JOINTS IN GENERAL. 609 involving the pleura, pericardium, meninges, or lung. In other cases ■the cHnical picture is that of a severe septicemia, viz., high fever, dry tongue, rapid pulse, delirium, etc. In a third class of cases, the arthri- tis is apparently primary without pulmonary localization. This latter variety is the one which is often secondary to a pneumococcus osteo- myehtis. The exudate is usually purulent. Arthritis Following Other Infectious Diseases. — Pain, swelhng, tenderness, and loss of function of a joint may appear during the course of a large number of other infectious diseases, e. g., scarlatina, measles, diphtheria, dysentery, influenza, cerebrospinal meningitis, variola, and secondary syphilis. The diagnosis of the nature of the arthritis can only be made if there is a history of the primary disease. The arthritis may be monarticular or polyarticular. The exudate is usually serous, rarely sero-purulent. Exploratory aspiration is rarely necessary in order to make a diagnosis. Gonorrheal Arthritis. — This form of secondary arthritis presents such a varied clinical picture that its recognition often presents great difficulty. Clinically and pathologically there are four forms : ^ I. Hydrops. This is the mildest form. The arthritis is usually monarticular. The joint most often affected is the knee. If fever and general disturbances are present they are shght. There is but httle pain, and the loss of function is chiefly due to the swelhng. The effusion is of a serous character, clear, and often of a greenish tint. 2 and 3. Serofibrinous and purulent forms. The symptoms are more intense. There is moderately high fever and tenderness, and the pain on movement is quite severe. The capsule is greatly thickened and there is more paraarticular involvement than in the serous form, so that anky- losis is not an infrccjuent sequela. 4. The phlegmonous form. This is the most virulent, and is often polyarticular. The local symptoms are best seen in superficial joints, like the ankle, wrist, or knee. This fourth, is the most characteristic form of gonorrheal arthritis and occurs in adults as a comphcation of a urethritis. In children it frequently follows a vaginitis, but it may occur in male babies (Holt) without other clinical evidence of gonococcus infection. It may involve only a single joint, but more frequently is poly- articular, representing a gonococcus pyemia. The disease may begin suddenly with severe pain, swelling, 1 I have followed the classification of Konig, which appears the most satisfactory. 39 6lO THE EXTREMITIES. tenderness, redness, and edema of the affected joint or joints. The general symptoms in such cases are extreme. There is but Httle fluid in the joint, the swelHng and pain being the most marked local signs. In a few cases intraarticular abscesses form at an early period. In children ^ the general symptoms are of a pyemic character with marked prostration. After such an acute onset, the course of the case becomes very chronic, resulting in complete destruction of the joint, i. e., its ligaments become lax, the cartilages are destroyed, and ankylosis follows. Gonorrheal arthritis may run a subacute or chronic course from the onset. The patients often complain of flying pains in the joints. There is no swelling, but loss of function and ankylosis frequently follow. The majority of cases of gonorrheal arthritis appears during the latter weeks of the acute stage of the disease. The condition also appears in the subacute or chronic cases. There is usually no difiiculty in making a diagnosis, even without a bacteriolo2[ic examination. The first steo is to examine the urethra for pus and the urine for clap shreds, and then stain for the gonococcus. The only form of acute arthritis which requires differentiation is artic- ular rheumatism. Both of these may begin as potyarticular lesions. Acute rheumatism is more apt to involve the smaller joints of the fingers or toes than is the gonorrheal form. In many cases the local signs are so similar in their severity as to make a differentiation impossible. The presence of a local gonorrheal infection should be sought for. If the gonococcus is found in the joint exudate, the diagnosis is confirmed. This latter is unfortunately a very difficult mode of diagnosis, and often results negatively. Gonorrheal arthritis is more frequently monarticular than is the ordinary acute form; there is also an absence of cardiac or other serous comphcations in the gonorrheal form, and a greater tendency to early ankylosis. In the more chronic forms of gonorrheal arthritis without much effusion and no tendency to ankylosis, the differentiation from chronic rheumatoid arthritis is very difficult. The most important point is to find the primary focus in the gcnito-urinary tract. Secondary Acute Arthritis by Extension. — This form of acute arthritis occurs both in adults and children. The diagnosis presents no difiiculty. Even in cases of this form of arthritis, following an acute osteomyehtis of the upper end of the femur or similar primary foci^ the ' Holt: "Medical Record," March ii, 1905. DISEASES OF THE BONES IN GENERAL. 6ll joint symptoms are so severe as to completely predominate the clinical picture. The exudate is usually purulent, and contains the same organisms as those which have produced the primary focus. Such secondary forms of arthritis may follow (a) infection of the bones forming the joint (acute pyogenic osteomyelitis) ; (6) phlegmon or erysipelas, or even lymphangitis around the joint; (c) a suppurative bursitis or tenosynovitis in the vicinity of the joint, where such structures normally communicate with the articulation; (d) penetrating wounds or operations upon the joints. Clinically the picture is that of a severe arthritis accompanied by marked constitutional disturbances. The primary cause can usually be ascertained. Chronic Arthritis. Although the division into acute and chronic arthritis seems an un- satisfactory one from a pathologic standpoint, it appears to correspond in the majority of cases to the more important clinical signs, such as mode of onset, local findings, etc. We shall see, however, that some of the forms of arthritis which are usually spoken of as chronic, i. e., slow and progressive in their course, begin quite acutely. For example, there is a group of cases of arthritis deformans, which have an acute onset and course, becoming gradually chronic. Similar exceptions are found in some of the other groups, such as acute forms of tuberculous and gouty arthritis. These occur, however, rather infrequently, and with a little consideration of the chief diagnostic features of each individual case, they can generally be placed under one or the other heading. Tuberculosis of Joints. — To this cause can be ascribed a large percentage of cases of chronic joint disease, and in the examination of such patients, especially in early life, this form of arthritis must always be thought of. As in many other joint diseases a knowledge of the pathology is a most valuable adjunct in making a correct diagnosis. The disease may appear primarily (a) in the bone, called the primary osteal form, and then either invade the joint, or cause paraarticular abscesses without any involvement of the joint; or (b) its first manifestations are in the synovial membrane, called the primary synovial form, the bone being involved after erosion of the articular cartilage. In general, the primary synovial is more frequent than the primary osteal form. In tlio hip and elbow, the reverse is the case. Clinically there are three forms, viz. : (a) A tuberculous hydrops. A slow accumulation of serous exudate 6l2 THE EXTREMITIES. takes place in the joint. Quite rarely, this form may pursue the acute course referred to above, the clinical picture greatly resembling that of an acute rheumatic arthritis. Accompanied by fever, pain, and swell- ing, several joints may be involved. (b) The fungus form. In this, there is a gradually increasing en- largement of the joint with pain, contractures, and slight increase of evening temperature. (c) Empyema of a joint. In this the joint also enlarges slowly, and contains a considerable amount of tuberculous pus. The chief diagnostic features of tuberculosis of the joints are as follows : 1. Pain. — This varies greatly, often being quite severe, while at other times it is of a dull, aching character. The pain is usually referred by the patient to the joint involved, but it may be felt as in the case of a tuberculous hip-joint in the knee. The pain is often more marked at night, the exacerbations causing patients to cry out in their sleep. 2. Tenderness. — This is a valuable sign if found. It can, of course, only be elicited by pressure over the ends of the bones which form the more superficial joints, like the ankle, knee, fingers, wrist, elbow, and shoulder. When present it indicates an osteal focus. In deep joints, like the hip, it can be elicited by tapping upon the knee (Fig. 431). 3. Swelling. — This is an early sign in primar}^ synovial tuberculosis. In the primary osteal variety it does not appear so early unless the dis- ease progresses rapidly. The swelling is uniform (Fig. 438). All of the normal depressions disappear, and the muscles above and below the joint atrophy. 4. Loss of Function and Rigidity. — This is one of the earliest signs. The limitation of movement is marked in all directions, every movement being accompanied by pain. In a primary synovial lesion, the move- ments may at first be but little impaired and are painless. As soon, how- ever, as the bone is involved, the limitations of motion and the pain become quite marked. 5. Position of the Limb. — This is often quite characteristic, and varies with the stage of the disease and the individual joint involved. This symptom will be referred to in connection with the special joints. 6. Onset and Course. — As a rule, joint tuberculosis begins insidiously, often weeks to months after a trauma. Its course varies according to the virulence of the disease and the treatment received. Deformities are a frequent sequela. The contents of the joint may penetrate the capsule in one or more places and form paraarticular abscesses, which gradually reach the surface of the limb and either form subcutaneous swellings, or DISEASES OF THE JOINTS IN GENERAL. 613 the pus is evacuated, sinuses forming with typical tuberculous bluish, undermined edges and lined by flabby, often caseous, granulations. 7. Family and Personal History. — It is of great importance in the diagnosis of joint tuberculosis to secure an accurate family history in order to ascertain if possible any hereditary tendency. In the same manner, information should be secured as to the occurrence of tubercu- lous lesions elsewhere, such as caseating lymph-nodes (Fig. 429), other osseous, cutaneous or pulmonary foci. A pleurisy with effusion is often . of tuberculous origin. 8. Temperature. — As a rule, there is but httle, if any, rise of tempera- ture. If any exist it occurs toward evening. At times one encounters cases with considerable fever. These are usually the result of a mixed infection. g. X-ray. — The 3c-ray is of considerable value in the diagnosis of tuberculous lesions, but unfortunately it only gives positive information at a rather advanced stage. This is due to the fact that skiagraphs of a tuberculous joint will only show absence of normal shadow, i. e., a defective clear area in the plate, when the bone itself has been affected. Its use will be referred to again in the diagnosis of tuberculosis of the individual joints. In very doubtful cases, a skiagraph should be made, since it will often aid in differentiating advanced tuberculosis from, arthritis deformans and chronic rheumatoid arthritis, although even here there is a chance for error. 10. Tuberculin Test. — The diagnostic value of tuberculin has been the subject of considerable discussion of recent years, and the general opinion is, that it is too unreliable a diagnostic agent to be depended upon. There are some ^ who beheve it is of great aid in the diagnosis of tuberculous joints, but this opinion is not shared by the profession in general. Differential Diagnosis. — Tuberculosis of a joint must be differen- tiated from a simple non-tuberculous joint effusion, from chronic gonor- rheal and syphihtic arthritis, from chronic rheumatoid arthritis and arthritis deformans. Chronic Serous Synovitis, i. e., a Non-tuberculous Joint Affection. — This usually begins acutely after an injury, and either persists, or dis- appears, to recur from time to time. It may, however, greatly resemble tuberculosis if it begins insidiously, causing a gradually increasing pain- less swelling of the joint. It is chiefly a disease of adults, so that it would rarely come into question in the diagnosis of joint disease in chil- dren. In adults it most often afl"ects the knee. There is an absence of ' W. S. Baer and H. W. Kennard: "Johns Hopkins Hosp. Bull.," Jan., 1905. 6 14 THE EXTREMITIES. bone tenderness, of limitation of motion, of pain, and of rigidity so fre- quently found in tuberculosis. The disease is not progressive; it tends to improve spontaneously. The hydrops often disappears and recurs. There is no formation of particular abscesses or sinuses. Chronic Gonorrheal Arthritis.- — In this form of arthritis, the history of its having begun acutely, and then becoming chronic, together with the finding of evidences of an old gonorrheal infection, are of great value. There is also a greater amount of paraarticular thickening, and more of a tendency to ankylosis at an earlier stage than is the case in tuberculosis. Arthritis Deformans. — This disease must be considered from the fifteenth year on, especially in the elbow-joint. In this form of arthritis the ends of the bones are palpably enlarged, and the capsule feels harder and firmer than in tuberculosis. Arthritis deformans also runs a much slower course, and is seldom accompanied by pain. It is also more apt to affect multiple joints. Chronic Serous Synovitis (Chronic Articular Hydrops). — This form of chronic arthritis is usually the sequela or outgrowth of an acute attack. The most frequent cause is an injury, i. e., a simple sprain or distortion of the joint. It may, however, appear in a gradual manner without any apparent cause. In those cases in which it directly follows an injury, the diagnosis is not so difficult. There is a history of an in- jury followed by an acute swelling, which has either persisted or has disappeared, or has recurred from time to time. To the latter clinical variety the term intermittent articular hydrops has been given. It has also been called recurrent effusion. Where the joint swelling has persisted after an injury, without inter- vals during which the exudate has disappeared, the case may greatly re- semble a synovial tuberculosis. In the latter, however, there is a greater amount of thickening of the capsule, and often a clear history of tuber- culosis in the family, or foci to be found elsewhere in the body. The course of a chronic serous synovitis is also more gradual, i. e., it ex- tends over a longer period. It is also characterized by an absence of fever, an almost painless course, only a slight crepitus, and an absence of pain on pressure. In the second form of chronic serous synovitis, i. e., where it appears gradually without apparent cause, the diagnosis is even more difficult. The joint may be filled with papillomatous growths or converted into a lipoma arborescens. In the majority of cases the disease involves the loiee-joint, then the elbow, ankle, and wrist. The joints are more movable than those of chronic articular rheumatism, and there is no chansre in the cartilages DISEASES OF THE JOINTS IN GENERAL. 615 and bones as in an arthritis deformans. There is a gradually increasing loss of function, and an accompanying accumulation of fluid. Arthritis Deformans. — This form of chronic arthritis has been wrongly called rheumatic gout, chronic rheumatic arthritis, rheumatoid arthritis, osteo-arthritis, drv' arthritis, and chronic articular rheumatism. We now know that it is a clinical entity characterized by a fibrous degen era- \ Fig. 413. — Anterior View of a Case of Ar- thritis Deformans in a Boy of Ten (Same as shown in Fig. 414). Note the characteristic rigidity and deformities of the wrists, elbows, fingers, and knees. Fig. 414. — Lateral View of Case of .\rthritis De- formans IN A Boy of Ten. Note the enlargement of the lower end of the femur and the characteristic deformities in the elbow- and wrist- joints and in the fingers. The spine could not be ex- tended further than is shown in the illustration, as a result of the same process. tion in the svnovial membranes and periarticular structures, as well as by atrophic and hypertrophic changes in the bone. It is most common in old age. According to some, it is of infectious origin, while others be- lieve it to be the result of changes in the central nervous system. There are five clinical forms, according to Osier and MacRae:^ I. Heberden's nodes. Nodosities develop gradually at the sides of ' "Journal of the American Medical Assn.," Jan. 2, 1904. 6i6 THE EXTREMITIES. the distal phalanges of the fingers about the thirtieth to the fortieth year. The larger joints are rarely involved, and the nodes seldom cause any symptoms. 2. Polyarticular or general progressive form. It may begin acutely with symptoms like an acute articular rheumatism. The chronic form is themore frequent, and the joints are involved symmetrically, usually those of the hands first, then the knees, hips, feet, and other articulations. There is a variable amount of pain. In some it is very severe, in others scarcely noticed. The pain is accompanied by more or less swelling of Fig. 415. — Dislocation of Both Wrists due to Marked Arthritis Deformans. The dislocation is more marked upon the right than upon the left side, and was of the forward variety, characteristic deformity of the fingers is also present. The the joint. Creaking soon begins, followed by inability to move the joint owing to fibrous ankylosis. The muscles of the limb atrophy, and contractures of the joint set in (Fig. 411). 3. The monarticular form chiefly affects old people, and is seen par- ticularly (Osier) in the hip, knee, spinal column, and shoulder-joint. In many the condition seems to directly follow an injury. The local signs and changes, viz., swelling, ankylosis, atrophy, and deformity, are the same as in the polyarticular form. 4, Vertebral form. The disease here causes a progressive ankylosis with resulting rigidity of the spine. It may be limited to one region or in- DISEASES OF THE JOINTS IN GENERAL. 617 f\ volve the entire spine, causing inability to flex or extend it. Pressure on the nerve-roots may cause great pain, paresthesia, and muscular atrophy. 5. In children and young individuals. The onset may be acute with fever or even chills, or gradual mth increasing limitation of motion and enlargement of the joints. In the hip of children and young adults it produces outward rotation, adduction, and flexion similar to coxa vara, under which heading it ^\'ill be considered. In children this form of chronic arthritis is often characterized by general enlargement of the lymph-nodes and spleen, to which complex of symptoms the name StilVs disease has been given. There is more involve- ment of the synovial mem- brane and soft parts of the joint in children, and less de- struction of bone and carti- lage than in adults. The diagnosis of arthritis de- formans is in general not diflicult in the advanced stages. In the earlier period, especially in the acute cases, the diagnosis is more difficult. The chief forms of arthritis from which it must be dif- ferentiated are the following : From Acute Articular Rheumatism. — The pain and swelling are usually more marked than in arthritis de- . formans. The disease rarely disappears in a joint to reappear in another one, a phenomenon so char- acteristic of rheumatism. The spine and jaw are seldom involved in rheumatism. The enlargement of the lymph-glands speaks for arthritis deformans, as docs the absence of cardiac involvement and the failure of the sahcylatcs. There is also more rapid muscular atrophy, and the joint symptoms persist, even though the temperature falls in arthritis deformans. From Gonorrheal Arthritis. — This may cause pain, swelling, stiffness, Fig. 416. — Marked Deformities of the Fingers and Wrists in a Girl of Sixteen due to Arthritis De- formans. 6l8 THE EXTREMITIES. and be polyarticular. It should always be excluded in every case (see page 609). Chronic Articular Rheumatism. — This is characterized by the gradual onset of pain and swelling in the joints. The pain is very liable to exacerbations during changes in the weather. In some cases there is but little swelling or pain, the chief signs being stiffness and crepitation in the joints. The disease may be limited to a single joint, such as the shoulder, hip, or knee. There is never any erosion of cartil- age or formation of new bone, as in arthritis deformans. The condi- tion is often accompanied by valvular lesions. Gouty Arthritis (Arthritis Urica, Podagra). — This form of joint disease may appear in (a) an acute, (b) a chronic, and (c) an atypical or irregular form. The chronic may be the outgrowth of the acute or appear gradually. Acute Gout. — In this form there is a sudden onset of severe pain (usually at night) in the metatarso-phalangeal articulation of the great toe. The cHnical picture is similar to that described as char- acteristic of other forms of acute arthritis, viz., severe pain, exquisite sensi- tiveness to pressure, redness of the overlying skin, fever, and swelling of the joint with obhteration of the normal depressions. The tempera- ture may arise to 103° F. The symptoms improve, only to recur from time to time. These acute attacks last about a week. Suppuration never occurs. After one or two attacks in one toe, the same joint of the other foot is apt to be affected ; later it involves the ankle- or knee-joints. The diagnosis usually presents no difficulties. The typical location of the acute joint swelling in a person who has been complaining of obscure pains all over the body, without gastro-intestinal disturbances, and has been a bon vivant or has led a sedentary hfe, should always lead to the suspicion of its being gouty in character. If the acute attack occurs primarily in other joints than those of the great toe, the diagnosis can only be made if tophi are found. These are collections of uric acid deposited in the external ear, the finger-joints, and later around the knee, elbow, etc. Another diagnostic point in favor of gout versus acute rheumatic arthritis is the fact that the output of uric acid is greatly dim- inished during the attack. Fever is more constant in acute rheuma- tism than in gout. If limited to the metatarso-phalangeal joint of the great toe it must be differentiated from a bursitis (see page 263). Chronic Gouty Arthritis. — -This is either an outgrowth of the attacks of acute gout or may be primarily chronic. The toes, and later the fingers, ankles, knees, and elbows, gradually increase in size and become deformed. DISEASES OF THE JOINTS IN GENERAL. 619 These enlargements are accompanied by deposits of uric acid around the affected joint capsule and in the ears. Ulceration of the skin over these tophi may occur. Accompanying these joint symptoms are often those of a chronic interstitial nephritis. These chronic cases can be differen- tiated from arthritis deformans and chronic rheumatism by the presence of tophi around the joints and in the ears, as well as by the constancy with which the acute attacks begin in the joints of the great toe. Atypical or Irregular Form. — -This is a group of cutaneous, gastro-intes- tinal, cardiovascular, ner- vous, and urinary sym- ptoms, which often ac- company more chronic forms of gouty arthritis, or may occur indepen- dently of it. Syphilitic Arthritis. Acquired Syphilis. — (a) Secondary Syphilitic Ar- thritis. — Quite rarely an acute swelling, indicating an effusion into the larger joints, occurs during the secondary stage. It is characterized by pain and effusion in one or more of the larger joints. Usually the knee is the only joint involved. The diagnosis can be made from the fact that the arthritis appears almost simultaneously with the first cu- taneous eruption, i. e., about seven to eight weeks after the initial lesion. The joint swelhng disappears rapidly after antisyphilitic treatment. (&) Tertiary or Chronic Syphilitic Arthritis. — During this stage a form of arthritis occurs which is most difficult to recognize. It resem- bles a tuberculous arthritis so closely, that at times a differentiation can only be made by the administration of iodids and mercury or by opening the joint. In the latter case one would see gummata in the synovial Fig. 417. — Tabetic Hip-joints. Note the enormous enlargement of the gluteal region, due to increased size of the articular ends of the bone. 620 THE EXTREMITIES. membrane or in the articular ends of the bone. The gummata are much larger and firmer than a tubercle, and are never caseated. If the disease is far advanced, ankylosis occurs, and antisyphilitic remedies produce no improvement. The history of a preceding syphilitic infection and the presence of evidences of the disease elsewhere, as well as the results of the thera- peutic tests, are the chief factors in making a diagnosis. The destruction of cartilage is seldom as extensive as in a tuberculosis and the tendency to deformity is far less marked than in tuberculosis. The absence of a primary focus of tuberculosis, or of a family history of this disease, will also aid in the diamosis. '^^~^-' ■ ... — -^ ■ "— ■ " ---«s«i Fig. 418. — Charcot Knee-joints. The illustration shows a typical case of disease of the knee-joint occurring in tabes dorsalis or locomotor ataxia, to which the name arthropathia tabetique of Charcot has been given. Note the enormous enlargement of the lower ends of both femorje, and the backward displacement of both tibia. The arthritis referred to above is that due to the presence of primary gummata in the synovial membranes. Another form is that which is secondary to a gummatous osteomyelitis, and is not so difficult to recognize, owing to the enlargement of the ends of the long bones pre- ceding the arthritis. The latter is most often found in the knee. Periarticular gummata also occur as localized tumors from hazelnut to walnut size, with but few subjective symptoms. It must be differentiated from the fibroma- tous form of tuberculous arthritis. Both of these conditions are very rare. (c) Arthritis in Hereditary Syphilis. — This appears usually in a DISEASES OF THE JOINTS IN GENERAL. 621 gradual manner, either with or without accompanying primary bone involvement. It most often alTects the knees, but may involve the wrists and elbows. It seldom appears before the sixth year. There is considerable swelling and thickening of the capsule, the latter in the form which is secondary to bone disease. Nocturnal pains are complained of. The epiphysis is often enlarged and may be entirely separated from the shaft. The loss of function in such a joint often gives rise to a condition known as pseudo- paralysis. Pus forma- tion is rare. The suspicion of hereditary syphilis should always be aroused if an apparently ichopathic, almost painless, spindle-shaped Fig. 4ip. — Anterior View of a Tabetic or Charcot Knee-joint, Which Had Been Suspected to Be a Sarcoma of the Femur. This is- the same case as shown in Figs. 420 and 421. Fig. 420. — View from Right Side of En- largement of the Lower End of Femur and Knke-joint in a Case of Tabetic Arthritis. Same case as shown in Figs. 419 and 421. swelhng of the larger joints, especially the knee or elbow, appears in a child, accompanied by loss of function of the arm or leg. The cornea, teeth, skull, and other epiphyses should be examined, and a careful history of the family and the infant's previous eruptions, coryza, etc., should be inquired into. These joints improve rapidly after antisyphilitic treatment. Neuropathic Arthritis. — This occurs after middle life with such comparative frequency that the possibility of an obscure joint affeclion being either of tabetic or syringomyelic origin must be constantly borne in mind. 622 THE EXTREMITIES. These two forms of arthropathy, viz., those due to syringomyeha and to tabes, differ somewhat in their dinical appearance. (a) Arthritis Tabetica (Arthropathie Tabetique, Arthritis N euro genica) . — The cKnical history varies greatly. In some cases the joint swelling appeared suddenly after a shght injury, and has persisted in spite of all treatment. In other cases the onset of the swelling was gradual, and attracted the attention of the patient only when it became quite marked and was accompanied by deformity such as subluxation, or by loss of function due to laxity of the Hg- aments. The joints most fre- quently affected are the knee, hip, and ankle, in the order named. In any case of joint disease in middle-aged or old persons, in which there has been a rapid painless swelling of the joint, the possibihty of tabes must be considered and a search for the classic symptoms made. These are so fully described in all of the text-books on internal medicine and neurology that it will only be necessary to men- tion the lightning-like pains along the back of the lower limbs, the absence of the patellar reflexes, the swaying of the body when standing erect with eyes closed, ataxic gait, the Argyll- Robertson pupils, the bladder and rectal paralysis, and finally the disturbances of cutaneous sensation. In the most typical cases, the knee or ankle is enormously enlarged, there is marked crepitus on manipulation, and the ends of the femur and tibia can be felt to be markedly enlarged. The latter may be so great that in the case shown in Fig. 422 the patient was referred to the writer with the diagnosis of osteosarcoma of the lower end of the femur. Accompanying the joint sweUing there is often a subluxation of one of the bones of the joint (Fig. 418). In many of the cases, the painless abnormal mobility of the joint is the most characteristic feature. This symptom and the rough crepitus are the chief factors in the diagnosis of Fig. 421. — Tabetic Knee-joint. The illustration shows the enormous enlargement of the lower end of the femur as a result of trophic dis- turbances and the abiUty to produce abnormal abduc- tion in the knee-joint. DISEASES OF THE JOINTS IN GENERAL. 623 tabetic disease of the hip-joint. The swelHng may disappear entirely in some cases, and then recur from time to time. In other cases there is no swelHng at any time, but a tendency to the formation of osteophytes in the joint capsule. The principal forms of arthritis from which it must be differen- tiated are tuberculosis and arthritis deformans. In neither of these is the swelling as painless as in tabes. Fig. 422. — X-RAY OF a Tabetic Knee-joint. Note the hypertrophic condition of the internal condyle of the femur which .simulated a neoplasm. Arthritis deformans often affects many joints, especially the smaller ones, and there is overgrowth of bone (hypertrophic form) with tendency to ankylosis. Tuberculosis is infrequent at the time of hfe when tabes appears. The joint swelling is seldom as marked as in tabes, and the capsule is usually tliicker. The swelHng leads to more or less fixation of the joint in tuberculosis, and not to abnormal mobility as in tabes. The previous history of the two affections and the examination for the nervous symptoms of tabes will clear up any doubts. 624 THE EXTREMITIES. (b) Syringomyelia. — This form of neuropathic arthritis differs from that of tabes in chiefly affecting the joints of the upper extremity. There are usually two forms: (a) As in tabes, there may be a sudden onset with joint swelling after an injury. In other cases the swelhng appears very slowly. In both instances the shoulder or elbow is most often affected. The sweUing itself is enormous, and the abnormal mobility and rough crepitus on manipula- tion very marked. (b) In the second form, the most striking feature is the tendency to recurrent dislocation, most often of the shoulder-joint. This may have appeared like the ordinary form of dislocation after an injury. The injury, however, is often of a trivial nature. Suspicion should be aroused in every such case, when the dislocation tends to recur upon the slightest amount of manipula- tion. This tendency to disloca- tion, accompanied by the enor- mous distention of the capsule, the painless course, and the rough grating sensation obtained on manipulation, should cause an ex- amination for the other symptoms of syringomyelia to be made. These are the occurrence of pain- less infections about the fingers and an absence of temperature and pain sense, so that the patient will burn or freeze his fingers without being conscious of it. In 80 per cent, of the cases of tabes the arthropathy is confined to the lower extremity, while in syringomyelia the same is true for the upper extremity. The clinical picture of both is similar (Figs. 419 and 423), viz., enormous swelling, relaxation of the capsule and liga- ment permitting of abnormal mobility or of complete or incomplete dislocations taking place. Fractures near the affected joint are more frequent in tabes. Both run an almost painless course. Hemophiliac and Scorbutic Joints. — Both of these may appear in an acute and chronic manner. The symptoms of both are practically the same, the chief difference Fig. 423. — Syringomyelic Disease of the Elbow JOINT (E. Graf). DISEASES OF THE JOINTS IN GENERAL. 625 being in the history of the case. In the acute form there is pain, fever, and marked swelhng of the joint. These all disappear, but may recur. In less severe cases there is only moderate swelling and pain, but no fever. In the chronic form the joint has passed through a number of the acute or subacute attacks just described, but remains swollen with thick- ening of the capsule, evidences of fluctuations, and enlargement of the joint ends of the bones. Adhe- sions are often present, caus- ing considerable impairment of mobility. The joint lesions can seldom be diagnosed as accompanying a general or scorbutic condition, or as occurring as a part of a general tendency to hemorrhage (hemophiha), without an accu- rate history and the thorough examination of the body in gen- eral. In the hemophiliac joints there is usually a previous his- tory, or some other obstinate hemorrhage from slight causes. The patients are often pale and anemic. The aspiration of the joint effusion shows it to be pure blood. Since blood, even in microscopic quantities, is rarely observed in any other form of non-traumatic arthritis, its presence should lead one to suspect either hemophilia, scorbutus, or a new growth. In scurvy (scorbutus) there is usually a history of an absence of some normally necessary factor in the diet, whether it occur in children or adults. In children there is such marked soreness about the loiees or ankles that they cry out with pain when lifted, and a condition of pseudo-paralysis results from inability to use the limbs. In adults the joint swelling is the most marked feature, and there is pain over the affected tibia or 40 Fig. 424. — View of Case of Tuberculosis of the Shoulder-joint from Outer Side, to be Com- pared WITH Normal Shoulder shown in Fig. 425- Note the atrophy of the deUoid from disuse, causing the acromio-clavicular articulation to become prominent; and also observe the fullness below the coracoid process, due to the thickening of the joint capsule, etc. 626 THE EXTREMITIES. femur. As in children, the knee- and ankle-joints are most often involved. In both children and adults the most important diagnostic sign is the spongy, swollen, bleeding gums, a foul breath, and a tendency to sub- cutaneous hemorrhages. Prompt improvement follows proper diet. Epistaxis is frequent in adults, and there is general anemia. The vast majority of hemorrhages occur in the knee, and most frequently in men. In purpura rheumatica the subcutaneous hemorrhages (Fig. 442) are usually a deciding factor, as is also the fact that many joints are usually involved. In the chronic form a scorbutic or hemophiliac joint may resemble a tuberculous arthritis, but there is usually some rise of temperature in the latter (99° to 99.5° F. in the afternoon). The course of a tuberculosis is also more progressive, and there are never any sudden exacerbations or remissions. When ankylosis exists the diiTerentiation from chronic rheumatic or tubercular joints is impossible, without a complete history. Tumors of Joints. These are very rare, and are chiefly benign in character, al- though a few cases of sarcomata of the larger joints (Fig. 408) have been observed. The most common of the benign forms are the joint lipomata first described by Volkmann in 1875.^ These cases are true lipomata, usually developing beneath the synovial membrane, i. e., ex- traarticular. They differ from a condition known as lipoma arborescens, in which there is an excessive deposit of fat in the normal joint villi. Both of the conditions just referred to occur most frequently in the knee-joint, but cases of its occurrence in the elbow and ankle have been described. The tumor extends into the joint, either carr}ang the synovial mem- brane or breaking through the latter. The principal symptom in these cases is a painless enlargement of the joint. The swelling is soft and doughy. Neuralgic or Hysterical Joints. This form of joint affection is found in neurotic persons, and may simulate genuine disease. The conditions may follow an insignificant injury, usually of the hip or knee, but it may appear in any joint after an injury and be made the basis, for damage suits. Any attempt at movement causes great pain. The joint motions are apparently restricted in all directions, but if the patient's attention is diverted or if he is anesthetized, all limitation of movement disappears. ^ Biochitzk)-: •' Beitrage zur klinischen Chirurgie," vol. xxiii. DISEASES OF THE INDIVIDUAL JOINTS. 627 The joint is often swollen and sensitive, as well as fixed. Intermit- tent hydrops may occur in such joints. In cases of long duration there is some atrophy of the muscles above and below the joint (Figs. 258 and 259), as a result of non-use. There is seldom any rise of local temper- ature, but even this may exist. Accompan3dng the joint symptoms are other signs of hysteria both in children and adults, and in men as well as in women. DISEASES OF THE INDIVIDUAL JOINTS. The clinical picture of both acute and chronic arthritis possesses cer- tain variations according to the joint involved. These depend upon the relations of the capsule to the overlying parts, as well as upon the accessibihty of the individual joint to direct manipulation. For ex- ample, the capsule of the knee-joint lies so close to the surface and extends over so great an area, that the recognition of changes both within and external to the joint is much easier than is the case with such articulations as the shoulder and hip. In the case of the shoulder but little of the capsule Kes close to the surface, while in the hip, the depth of the joint prevents any direct recognition of changes. It is therefore important to be able to search for certain clinical characteristics of each individual joint. The following table may be of some assistance: Swelling First Appears. Shoulder Anteriorly between coracoid and head of humerus. Elbow On both sides of olecranon. Wrist On dorsum. Finger-joints . . .On dorsum. Sacroiliac On back of joint. Hip Invisible until later, then in front. Knee On all sides of patella. Ankle Over front of joint and" below malleoli. Tarsal joints.. .Invisible. Toes On dorsum. Pain. Over joint and along arm. Over joint. Over joint. Over joint. Over joint and along back of limb. Over joint and to knee. Over joint. Over joint. Over joint. Over joint. Most Characteristic Position. Adduction. Flexed at acute right angle. Slight flexion. Flexion. No change. Varies according to stage (p. 634). Flexion, later sublux- ation of tibia'. Flexion. No change. Flexion. Shoulder-joint. Acute arthritis, exclusive of the traumatic form, is infrequent in this articulation, and has no special characteristics. The most com- 628 THE EXTREMITIES. mon forms of chronic inflammation are tuberculosis, rheumatism, arthritis deformans, and syringomyelia, as well as the various forms of post-traumatic ankylosis. Tuberculosis of the shoulder- joint is a comparatively rare affection. It begins insidiously with pain on motion and there is a dull aching pain when the limb is at rest. The pain is often neuralgic in character, and is always worse at night. The shoulder appears fuller in front, be- tween the coracoid and humerus, and there is usually marked atrophy of the deltoid, so that the acromion is quite prominent. The arm is adducted to the side of the body. Abduction, both active and passive, is difficult, and accompanied by pain. When suppuration occurs, the sinuses appear in the axilla and over the front and back of the joint. There is usually no diffi- culty in distinguishing a subdel- toid bursitis from an arthritis of the shoulder. The two may however coexist, especially in tuberculosis. Elbow-joint. The majority of forms of acute and chronic arthritis of this joint are accompanied by effusion and changes in the cap- sule. The swelhng is most marked on either side of the ole- cranon process, and the early at- rophy of themusclesof the arm and forearm, gives the joint enlargement a spindle-shaped appearance. If the effusion is extensive, fluctuation may be easily ehcited over the back of the joint. The joint is held rigid in a flexed position, either at a right or an acute angle. Pronation and supina- tion are greatly hmited. If the tuberculosis is limited to the head of the radius, there is marked absence of rotary power and localized swelling. Sinuses are most apt to be found upon the posterior and lateral aspects of the joint. Fig. 425. — View of Xurmal Shoulder prom Outer Side. To be compared with Fig. 424. (Case of tuber- culosis of the shoulder-joint.) Observe the depression below the coracoid process on the normal side, as com- pared with fullness on the diseased side. DISEASES OF THE INDIVIDUAL JOINTS. 629 ■Wrist-joint. This joint lies so superficially that but httle effusion is required to obhterate the normal depression upon the back of the wrist. The most common affection of the chronic variety is tuberculosis. In this there is swelling on the back of the wrist. The wrist-joint is stiff, and any movements are accompanied by pain. The hand is held flexed on the forearm. As in the case of the other joints, the degree of swelhng can be Fig. 426. — Tuberculosis of the Shoulder-joint, showing the Limitation of Motion on the Dis- eased Side, and Characteristic Abduction Deformity. On the normal side the arm could be raised up easily to the level of the head; on the diseased side it could only be voluntarily abducted from the body about forty-five degrees. estimated by comparing its circumference with the joint of the oppo- site limb. Finger-joints. These arc frequently the scat of acule rheumatic arlliritis and of gouty and chronic rheumatic arthritis, as well as of arthritis deformans. Tuberculosis may occur independently of an osteomyelitic focus, but is usually associated willi Ihc latter (Fig. 398). The swelling is always more distinct on llic dorsum. In acute forms tlie ])osition is one of extension, wliile in llie chronic forms llexion and lateral deviation are more common. 630 THE EXTEEillTIES. Special attention must be called to a form of septic arthritis, caused by a bite, the teeth entering the metacarpo-phalangeal joints while they are flexed. They run a subacute course and are often overlooked, the case being treated as one of ordinary subcutaneous phlegmon. Sacroiliac Joints. This occurs very rarely, and usually in young adults. Tuberculosis is practically the only form of disease of this joint. Pain is felt by the patient over the articula- tion, which is often worse at night. The joint is also sensitive to pressure. The pain radiates do^^^l the thigh, and is increased when the patient sits do^Mi. The patient attempts to step as hghtly as pos- sible upon the toes of the diseased side, so that limping is quite marked and the pelvis compensa- torily lowered. There is often swelling to be seen and felt posteriorly over the articulation. When the ihum is grasped on the diseased side and attempts made to move it, the pain in the joint is greatly increased. Abscesses open either posteriorly or burrow along the pelvic fascia to open in the lumbar or gluteal regions, in the ischiorectal fossa, or even in the inguinal region. Disease of this articulation must be differentiated from lumbago, sciatica, from hip-joint cHsease, and tuberculosis of the sacrum or verte- bras. It can be differentiated from lumbago by the fact that the pain is higher up and is not locahzed, as in sacroihac disease. In sciatica the predominant symptoms are pain over the sacrosciatic notch, which radiates down the back of the thigh and then into the foot. There is no tenderness over the sacroiliac joint, and the patient does not hold the pelvis rigid or cry out with pain when the ilia are pressed together. Fig. 427. — ^AxTERiOR View of Case of Tuberculosis of the Shouxder-jokt. X, Xormal shoulder- joint; T, tuberculous. Note the prominence of the diseased side. DISEASES OF THE INDIVIDUAL JOINTS. 631 From tuberculosis of the spine sacroiliac disease can be distinguished by the fact that one or more of the spinous processes are prominent, and there is marked reflex rigidity higher up than is the case in sacro- iliac disease when movement is attempted. From coxitis it can be differentiated by the presence of rigidity, when attempts are made to carry out movements of the hip-joint. The pain is felt in the hip or knee, and not over the sacroiliac joint. In diseases of the latter joint, when the pelvis is fixed, all movements of the hip are free. In advanced cases of hip-joint, sacroiliac, and Pott's disease, when many sinuses are present it is often impossible, before operation, to state the pri- mary source of the pus. Diseases of the Hip-joint (Coxitis). Acute affections of this joint are infrequent. The acute arthritis following an osteomyelitis of the upper end of the femur in chil- dren has already been re- ferred to (page 579 ) and will be taken up later under the head of differential diagnosis of tuberculosis of the hip. Acute arthritis of the joint occurs during all of the infectious diseases mentioned as causing arthritis (see page 602). The diagnosis in such cases can be made {a) from the history of the primary infection; {h) from the presence of severe pain referred to the hip or knee; {c) from the marked limitation of movement of the joint, the reflex muscular spasm causing almost absolute fixation; {d) from the presence of fever and other signs of acute inflammatory reaction. In some cases the patients are not seen during the acute stage of coxi- tis. The surgeon is consulted on account of a deformity resulting from it. This may be either in the shape of an ankylosis or of a dislocation. The diagnosis in cither case rests upon the objective findings taken in Fig. 428. — Posterior \'iew of Case of Tuberculosis of the Elbow-joint. N, Normal arm; T, tuberculous. Note the characteristic obliteration of the depressions on either side of the olecranon process. (See Fig. 429.) 632 THE EXTREMITIES. conjunction with the previous histor}^ Such apparently spontaneous dislocations following an acute coxitis have been reported after ty- phoid, scarlatina, acute rheumatism, influenza, etc. Another form of acute coxitis to be mentioned is that resulting from gonorrhea. As is the case in all of the forms of metastatic gonorrheal arthritis, there is an early tendency to marked ankylosis. It is most apt to oc- cur in young adults. The most impor- tant disease of the hip-joint is tubercu- losis. It is the one from which the ma- jority of the acute forms must be differ- entiated, both at the time of the onset and, if seen at a later per- iod, after all of the acute symptoms have disappeared. Tuberculosis of the Hip-joint (Tu- berculous Coxitis). — The examination of a child or adult for the purpose of mak- ing a diagnosis of this common affection should be conducted in a more or less sys- tematic manner, as follows : I. Detailed his- tory of the case. 2. Inspection. To determine (a) the presence of lameness; (b) the position in which the hmb is held, /. e., its attitude during walking, standing, or upon lying down. 3. Palpation. To determine (a) whether there is fixation of the joint, Fig. 429. — Tuberculosis of the Elbow-joint. Note the depressed scar in the supraclavicular region following an operation for tuberculous lymph-nodes of the neck. This was probably the primary infection, having preceded the elbow-joint disease by five years. (See text.) Observe the characteristic fle.xion of the elbow, which occurs in all diseases of the elbow- joint, the forearm and hand being held in a position of half supination and half pronation. Observe the prominence on the outer aspect of the elbow- joint, replacing the normal depression between the olecranon and the e.xternal condyle: DISEASES OF THE INDIVIDUAL JOIXTS. ^33 i. e., limitation of its normal movements; ih) whether any swelhng is present; (c) whether tapping upon the trochanter or knee causes pain. 4. Measurement. To determine the presence of muscular atrophy and of shortening. 5. X-ray examination. 1. History. — This should include not only the mode of onset, but also whether there is any tuberculosis in the family, or evidences of recent or old foci elsewhere in the patient. The usual history of the mode of onset is that it has been gradual. In but few cases does the disease begin suddenly. There is not infrequently the his- tory of a fall upon the trochanter or of other injury to the limb. The first symptom noticed by the parents is that the child be- gins to hmp, and the hip is held a httle rigid. In addition the child complains of pain in the hip or in the knee, which is increased by any movement of the affected limb. Often these pains are in- creased at night, so that the child awakens from a sound sleep with an outcry of sudden pain. Intelhgent parents will often give such a history of gradually increasing lameness, stiffness of the hip, and pain that the attention of the surgeon is at once attracted to this joint. 2. Inspection of the Limb. — This will give much information, and the child should be thus, examined, if possible while standing, walking, and lying down, being stripped of all suiJcrfluous clothing. The child is seen to limp, resting as httle weight as possible upon the toes of the diseased hmb. The pelvis is elevated upon this side, so that the limb appears shortened. When the two anterior superior spines are outhncd on the skin, this compensatory tilting of the pelvis can be well seen. Inspection will further reveal any changes in the attitude of the limb. This is a very common and prominent symptom, Fig. 430. — Appearance of Hands in Acute Rheumatic Polyartic- ular Arthritis. 634 THE EXTREMITIES. and is due to the reflex muscular spasm. It is inadvisable to divide tuberculous coxitis into three stages according to the position of the limb, for the reason that these are so inconstant as to lead to much con- fusion. This is especially true of the early stage. In the early period the limb is usually abducted and rotated outward, but not always flexed. In the later stages the attitude of the limb is far more uni- form. At such time there is marked adduction, internal rotation, and flexion. The limb in the early stages appears to be shortened, but, as Fig. 431. — Various Positions in Hip-joint Disease (Edmund Owen). I, Compensatory lordosis in hip-joint disease; 2, method of estimating degree of flexion of the hip, when back touches table; 3, amount of fixation of hip-joint. The normal left hmb can be flexed upon the ab- domen; the diseased limb forms the angle shown in the figure. has just been explained, this is the result of tilting of the pelvis. In the later stages the shortening of the limb is genuine, due to actual loss of bone substance. Abduction of the hmb causes the pelvis to be raised, while adduction results in its being lowered. The flexion of the joint causes a com- pensatory lordosis, and the degree of flexion can be readily estimated. 3. Palpation for Limitation of Motion, Location of Pain, and Swelling. — Palpation yields much information of diagnostic value. DISEASES OF THE INDIVIDUAL JOINTS. 635 The child should be laid upon a firm couch or table and the range of motion upon the healthy side first ascertained, as this will often clear up the question as to whether any rigidity is due to the child being frightened. The suspected limb should be held at the knee with one hand while the other grasps the pelvis. close to the hip (Fig. 327). The examina- tion should determine whether there is any hmitation of abduction or adduction of the limb. When this movement is limited, the pelvis moves with the diseased limb. The des^ree of flexion can either Fig. 432. — Method of Tapping Knee to Determine Tenderness in Cases of Suspected Hip-joint Disease. The patient's knee-joint region is allowed to rest upon the surgeon's left or right hand, as the case may be, while the opposite hand taps upon the region of the patella. be determined while the patient is lying upon the back (Fig. 430) or upon the abdomen. Under normal conditions a child lying upon its back shows only a slight amount of lordosis of the lumbar portion of the spinal column (Fig. 432) when the hmb is fully extended. In hip-joint disease a marked lordosis will appear (Fig. 430) when attempts are made to extend the limb. The degree of flexion can be roughly determined by allowing the lumbar spine (Fig. 432) to touch the table. Such a test cannot be used where much pain exists. If the patient lies upon the abdomen the amount of flexion can be de- 636 THE EXTREillTIES. termined by placing the hand upon the sacrum and alternately raising the affected and the normal hmb. In case there is limitation of inward and outward rotation, the thigh is flexed to a right angle while one hand grasps the knee. Efforts are then made to turn the femur outward and inward. In the early stage of hip-joint disease, the motions which are Hmited are abduction, h}'perextension, and rotation. In the later stage, the motions are limited in all directions. Location of Pain. — Palpation is also utilized to determine the pres- ence of pain and of swelhng. Referred pain, however, mav not be present at any stage of the disease, and is not nearly so valuable a diagnostic sign as the others mentioned here. When present, pain is usually felt on the inner side of the thigh, close to the knee-joint. Pain Fig. 433. — XoRMAL Degree of Lordosis of Speve. Note the slight forward curvature in lumbar region of a child King in normal supine jxjsition. in the joint itself is less constant. There is often sensitiveness to pres- sure over the trochanter and when the knee is gently tapped (Fig. 431). Pain is also quite marked upon pressing deeply over the front and back of the joint. SweUing. — There is often a distinct thickening to be felt over the head of the femur at Scarpa's triangle or behind the trochanter. This sign is ver}- difhcult to elicit, especially in the more acute cases. There is at times enlargement of the inguinal glands below Poupart's ligament. Abscesses usually appear over the front of the joint, but may gravitate toward the trochanter or downward toward the knee. Similarly, sin- uses may be present at any point. 4. Measurements of the Limb for Shortening and Atrophy. — The apparent shortening referred to, as existing in the early stages can DISEASES OF THE INDIVIDUAL JOINTS. 637 be ascertained by the methods of measurement of the hmb as described on page 493. Later in the disease, this same measurement reveals an actual shortening, var}'ing according to the amount of destruction of the head and neck. The presence of atrophy even at an early stage is a diagnostic sign of considerable value in this disease. The degree of muscular atrophy is ascertained by measuring the circumference of both hmbs at the middle of the thighs (Fig. 434) and middle of the legs (Fig. 435). In the later stages a rectal examination should never be omitted, for evidences of perforation of the acetabulum, with resultant intra- pelvic inflammatory induration and abscess formation. 5. X-ray Examination. — As was stated in the consideration Fig. 434. — Method of Determining the Circumference of the Thigh at its Middle. (See te.xt.) of the diagnosis of joint diseases in general, this mode of examination can only be utilized at such a late period in tuberculous arthritis, that a diagnosis is possible in the majority of cases without it. This is especially true of the hip-joint, where the destruction of bone must be fairly extensive before it will show in a skiagraph. DiJfferential Diagnosis.-^i. PoWs Disease {Tuberculous Spon- dylitis). — A tuberculous lumbar spondylitis may greatly resemble hip- joint disease, owing to the hmb being held in a rigidly flexed position. There is, however, no limitation of the motions of rotation, abduction, or adduction of the hip. When attempts are made to extend the hip no compensatory lordosis appears, the spine being held rigid. This latter symptom of spondyhtis is more distinctly brought out when 638 THE EXTREMITIES. the child is asked to sit up, after lying upon the back. It will employ every effort to raise and support itself by the use of the hands, in order to keep the infiamed lumbar spine rigid. The pains are referred to the spine or along the lower abdominal nerves, and are usually sym- metrical. 2. Chronic Arthritis Deformans {Morbus Coxoe Senilis). — This might come into question in elderly patients more often than in children, in whom it is infrequent. There is marked crepitation when the hip is rotated. The movements are only slightly limited. The x-ray would show bony hypertrophy. 3. Acute Osteomyelitis of the Upper End of the Femur. — The pain is far more acute than in tuberculous coxitis, there is high fever, and Fir.. 435,- — Method of Measuring the Circumference of the Lower Limb at the Level of the Mid- dle OF THE Calf. (See text.) much swelling about the hip. There are other signs of general infec- tion, such as a rapid pulse, leukocytosis, and often delirium. The de- struction of the bone is rapid, and abscess formation and shortening occur at an early period. 4. Rheumatic and Other Forms of Primary and Secondary Arthri- tis. — In these the history of the previous infection is of the utmost impor- tance, since the symptoms greatly resemble those of tuberculous cox- itis. They can be distinguished from the latter only by their shorter course and the previous history. 5. Coxa Vara. — The differential diagnosis of this affection is con- sidered on page 647. 6. Neoplasms of the Head of the Femur. — Both carcinoma and sarcoma of distant organs may be followed by metastatic deposits DISEASES OF THE KNEE-JOINT. 639 in the head of the femur and simulate tuberculous coxitis, on account of the pain, rigidity, swelhng, and shortening. In the case shown in Fig. 409 there was also evening rise of temperature. The diagnosis rests upon an accurate previous history, the examination of the remainder of the body for primary growths, and the x-ray. 7. Inflammation of the Iliopsoas Bursa. — This may also cause abduc- tion, outward rotation, and flexion of the thigh, as well as pain radiat- ing to the knee, x^dduction and inward rotation are impossible with- out an anesthetic, while abduction and outward rotation are free. The SPB PPB Fig. 436. — Location of Various Collections or Fluid in the Vicinity of the Knee-joint ^4, Effusion into the Icnee- joint, and suprapatellar bursa: i^, Femur; T, tibia; 5PB, suprapatellar bursa; PPB, location of prepatellar bursa; IPB, intrapatellar bursa. B, This illustration shows the simultaneous collection of fluid in the prepatellar bursa (PPB), and within the knee-joint itself. swelling over the joint is more marked than in coxitis, and deep fluc- tuation can often be obtained. Abscesses of this bursa may rupture into the hip-joint and vice versa. DISEASES OF THE KNEE-JOINT. No joint of the body is more frequently the seat of the various forms of acute and chronic arthritis than the knee. It will be unneces- sary to repeat the chief diagnostic points of these affections, since in every case one must make the diagnosis by the process of exclusion outhncd in the discussion of joint diseases in general. The local signs vary accorch'ng to tlie nature of tlie ])rocess, /. c, whether it be 640 THE EXTREMITIES. acute or chronic, and again whether the effusion be serous, seropu- rulent, hemorrhagic, or purulent. The following signs are common to the majority of the acute and chronic processes: 1. Pain in the knee and tenderness on pressure, especially along the lines of reduphcation of the capsule. 2. Obliteration of the depressions on all sides of the patella. This may either be due to the presence of fluid in the joint itself or in the sub- crural bursa, or it may be the result of thickening of the capsule or of a peri- articular infiltration. 3. Ballottement of the patella. This is to be found if only a small quantity of fluid be pres- ent. It is elicited either by tapping hghtly on the patella or by placing the index-fingers upon it and exerting pressure. With either method the patella springs back again when the pressure is relieved. Fluid in the prepatellar bursa causes fluctuation in front of the patella, and the latter cannot be made to dance upon the fluid as is the case with an intra- articular effusion. In ad- dition to this sign, the prominence is only over the patella, and there is but little, if any, obliteration of the normal depressions around the patella (Fig. 439). 4. The position or attitude of the hmb. The knee in the more acute cases is held rigidly extended at first, but gradually flexion takes place. As the cartilages become eroded and the ligaments relaxed various deformities occur. These may be (a) extreme flexion; (b) Fig. 437. — Side View of Knee-joint in a Case of Acute Synovitis. The arrows point to the spaces above and below the patella, which are depressions in the normal knee-joint, becoming ob- literated and bulging as soon as fluid collects in the knee-joint. DISEASES OF THE KNEE-JOINT. 641 subluxation of the tibia (Fig. 417); (c) genu valgum or genu varum, or even genu recurvatum, i. e., backward curvature or hyperextension. 5. Manipulation of the limb may reveal crepitus, either due to adhesions or fibrinous deposits or to erosion of cartilage. It may also show relaxation of the hgaments (Fig. 335) or enlargement of the arti- cular ends of the bones. 6. In the acute and chronic suppurative processes, sinuses may form on all sides of the joint and lead by a tortuous route to the inside of the capsule. The most frequent form of inflammation of the knee-joint or gonitis Fig. 438. — Method of Determining the Presence of Fluid in the Knee-joint, by Ballottement OR Dancing of the Patella on the Underlying Fluid. Two fingers are placed at the upper level of the patella and two at the lower, and alternately pressure is made. The patella can then be felt to be pushed back and forward, springing back, as it were, like a solid body when itis pressed upon while lying in water. is the tuberculous, and brief reference must be made to its chief diag- nostic features. Tuberculosis of the Knee-joint (Tuberculous Gonitis). — This may occur in those who are enjoying apparently the best of health, as well as in those who have marked evidence of tuberculosis elsewhere. Some cases apparently follow a trauma. In the majority of cases, however, such an injury is a very remote one, and has little lo do with the devel- opment of the process. The more important symptoms of diagnostic value are swelling of the joint, tenderness on pressure, pain, fixation, atrophy, local heat, and, later in the disease, deformities. 41 642 THE EXTREMITIES. I. Swelling. — This is usually most marked on either side of the patella. When muscular atrophy of the thigh and leg takes place the limb assumes a typical spindle shape (Fig. 438). The swelhng has a semifluctuating or elastic consistency, due to the granulations ■within the joint and to the iniilttation of the capsule and periarticu- lar tissues. It is the action of the latter upon the overlving skin, caus- ing it to be glazed and anemic, which gave this form of tuberculosis the old term of "tumor albus." If the joint contain either a serous or purulent effusion as the result of the tuberculous process, there is more distinct fluctuation, the space above the patella is filled out, and the patella itself shows the phenom- enon of ballottement. If such a joint eilusion recurs from time to time and explorator}^ puncture shows it to consist of fibrin or to contain rice bodies it should be regarded as strongly suspicious of tuberculosis. In some cases the diagnosis may be made if a palpable thickening of the capsule remains after the fluid has disappeared. 2. Pain, Tenderness, and Local Heat. — There is but little pain, ex- cept in the more acute cases, and the same is true of local heat. Tender- ness is present especially over the upper end of the tibia. The more acute the process, the more marked are the local pain, heat, and tender- ness. 3. Rigidity, Atrophy, and De- formity. — The patient walks with a decided limp, the knee being held rigid. The muscular fixation is not so great as in the hip-joint, and many cases permit of quite free manipulation. ^Muscular atrophy appears early and is usually quite marked. The position is at first that of mild flexion, the leg being rotated slightly outward. As the process advances the flexion deformity becomes more marked and may be accompanied by subluxation of the tibia, the latter lying in a plane behind that of the femur (Fig. 418). An enlargement of Fig. 439. — ^Anterior View of a Case of Ad- vanced TUBERCIILOSIS OF THE KnEE-JOINT (Left). Observe how the depressions normally exist- ing on all sides of the patella have been obliter- ated, especially that above the pafella correspond- ing to the seat of the suprapatellar bursa. DISEASES or THE KNEE-JOINT. 643 the lower end of the femur and a genu valgum position is also frequently found in advanced cases. 4. Abscess, Sinus Formation, and Fever. — As a rule, there is only a slight rise of the evening temperature, 99° to 100° F., but in some cases, the formation of pus not only manifests itself by an increase in severity of the local symptoms, but also by a considerable rise in the general temperature, at times to 103°. In such cases one often ques- tions the possibility of the process being of a tuberculous nature with- out the history of its gradual onset, the presence of the disease else- where in the patient himself or in his family, and lastly the fact that the capsule feels much thicker than is the case in an ordinary acute arthritis. Abscess formation may also occur from extraarticular foci. These are usually found as quite localized, distinctly fluctuating swelling over the tibia or one of the condyles. Sinuses may be present on all sides of the joint. 5. X-ray shows erosions of cartilage and foci in bones. Differential Diagnosis. — i. From some of the acute forms of arthritis. The resemblance of some cases of acute pus forma- tion in tuberculous knees to other forms of acute arthritis has just been referred to. Of these latter there are some which require special men- tion, viz., acute gonorrheal or gonitis, the acute forms of hemophihac gon- itis and some cases of monarticular acute rheumatism (Fig. 442). These can only be differentiated by the history of gradual development in tuber- culosis, followed by acute symptoms. In the gonorrheal form the history and local examination of the urethra will clear up the diagnosis. In the hemophiliac arthritis there is not so much pain or tenderness or fever, and exploratory puncture reveals l)lood. Tlic history will also be of the greatest aid. The monarticular rheumatic arthritis yields readily to appropriate treatment and is at times accompanied by a purpuric skin eruption (Fig. 442). Fig. 440. — Lateral View of Same Patient shown IN Fig. 438. Illustrating the characteristic flexion deformity, and the prominence of the suprapatellar bursa;. 644 THE EXTREMITIES. Both in children and aduhs a swelhng of the knee-joint may persist for a long time after an injury. It may disappear and then recur as described on page 614, the question often arising as to whether the process is a tuberculous one. In children, effusions which persist for a considerable period after an injury, must be looked upon with suspicion. In adults such a chronic, often recurrent effusion, if tuberculous, is apt to be accompanied by the capsular thickening and other signs just described. Other conditions which must be considered in the differential diagnosis are arthritis deformans, tabetic arthropathy, sarcoma of the Fig. 441. — Characteristic Flexion DEFORinTY in a Child Suffering from Teberculosis of the Right Kivee-joint. Xote the swelling above and below the patella, and the absence of normal depressions. femur and tibia, hpomata of the joint and hysterical joints, as well as diseases of the periarticular bursae (page 566). DISEASES OF THE ANKLE-JOINT. The acute forms of arthritis require no special mention, the most frequent of these being due to acute rheumatism, gonorrhea, and to trauma. Of the chronic forms those due to tuberculosis and tabes are of chief interest. The tabetic joints occur frequently enough in middle hfe to lead to errors in diagnosis. The local signs of the disease, viz., enormous enlargement of the joint, abnormal mobility in all direc- tions, without pain and marked crepitation, combined with the more general evidences of tabes, serve to make the diagnosis comparatively easy. DISEASES OF THE ANKLE-JOINT. 645 Tuberculosis of the Ankle-joint. — i. Swelling. As in all effu- sions into the ankle the first evidences are seen by a fullness of the depressions over the front and later along the lateral aspects (below the malleoli and behind the joint). The swelling has the same elas- tic consistency as in diseases of the knee-joint, soon giving rise to the typical spindle-like shape, through atrophy of the leg muscles. 2. Gait and position of foot. The patient walks very lame, the foot is held in an extended and somewhat adducted posi- tion. The ankle is held rigid. 3. Pain and tenderness. Pain is present at an early stage and causes marked lameness, so that the patient steps very lightly on the dis- eased foot. There is tender- ness on pressure over the en- tire joint. Attempts at move- ment of the joint and pres- sure of the foot against the leg cause great pain. Differential Diagnosis. — The principal conditions from which tuberculosis of the ankle-joint must be dif- ferentiated are the chronic forms of arthritis of this joint following injury and tuber- culosis of the tarsal joints. In the chronic traumatic form there is an absence of the peculiar boggy elastic swell- ing, there is much less pain, and if tenderness is present, it is not so diffuse. Tiihercidosis 0} the Tarsal Joints {Mcdio-tarsal and Tarso-tarsal).— In many cases if sinuses are present and the foot is uniformly swollen a differentiation is impossible. In general, however, the pain, tender- ness and swelling are in the anterior and middle portions of the foot and over the particular joint in\olved, wliilc the movements of the ankle-joint proper are free and painless. In primary tuberculosis of the os calcis there is swelhng behind Fig. 442. — Purpura Rheumatica Associated with En- LARGEJIENT OF THE LeFT KnEE-JOINT OF A RHEUMATIC Xature. 646 THE EXTREMITIES. the ankle-joint only. The bone itself is thickened and tender, and, if sinuses are present, the probe encounters rough bone. DEFORMITIES. Congenital Dislocations. Of the Hip. — This occurs most often in female children, and the attention of the physician or surgeon is seldom drawn to the condition until the child begins to walk. At such a time the gait of the child resembles the waddling mode of locomotion of a duck. This is most marked if the af- fection is a bilateral one. If it is present on one side only, the child seems to suddenly sink when stepping upon the foot of the affected side. This sudden shortening of the limb is due to the fact that the head has no fixed point, as is the case with the normal head in the acetabulum. It slides up on the ilium when the child rests its weight on the affected limb and causes this marked limping. The most important diag- nostic signs are: 1. A waddhng gait in bi- lateral, and the characteristic limp or sudden shortening in unilateral dislocations. 2. The trochanter lies above the Roser-Nelaton hne, as in a traumatic dislocation, but it can be pulled down by force. 3. The limb is shortened, as compared with its fellow, in unilateral dislocations. This varies from i to 3 cm. in children one to two years of age to 8 cm. in older ones. 4. On deep palpation one can usually feel the head of the femur upon the dorsum ihi. This is best done when the child hes upon its \ Fig. 443. — Double Congenital Dislocation of Hip (from a photograph in the collection of Dr. J. E. Moore). DEFORMITIES. 647 back and the limb is rotated with one hand, while the other grasps the head. The head can be pulled down by traction upon the limb. 5. The Trendelenburg sign. When a normal child stands upon either limb and flexes the other at the knee and thigh, the opposite buttock will not be seen to drop. In the child with congenital dislo- cation, however, the opposite healthy buttock will be seen to drop when the child stands upon the affected limb so that the gluteal fold is at a lower level. This is due to the fact that the gluteal muscles upon the dislocated side are unable to perform their function of keeping the pelvis level. Fig. 444. — X-RAY OF Congenital (Right-sided) Dislocation of the Femur at the Hip-joint. 6. There is a marked lordosis and scoliosis toward the affected side. If the lesion is bilateral the lordosis is very striking. 7. The x-ray examination is of great value, especially in young infants who are quite fat, the head and trochanter being difficult to palpate (Fig. 444). Differential Diagnosis.^Coxa Vara (see page 648). — In this affection the head cannot be felt in an abnormal position. It resem- bles congenital dislocation in the fact that the Hmb is shortened and that the trochanter lies above the Roser-Nelaton hne. Coxa vara is seldom observed at as early an age as a congenital dislocation. There is also an absence of the freedom of motion seen in the latter affection. In coxa vara there is marked hmilation of a1)(luction and of inward 648 THE EXTREMITIES. rotation. In case of any doubt a skiagraph will clear up the diag- nosis. Paralytic Flail Joint {Paralytic Dislocation). — In this condition there is also displacement of the head, the trochanter lies above the Roser-Nelaton hne, and there is lumbar lordosis. There is usually evidence in the thigh and leg of extensive paralysis, and atrophy or shortening (Fig. 450). Dislocation Following Arthritis 0} the Hip. — The symptoms of the spontaneous forms of dislocations of the hip, following some of the infectious diseases, resemble those of the congenital form in almost every particular. There is, however, usually a history of the primary affection, and the fact that before the onset of the latter, the patient was able to walk perfectly. The motions of the hip are also not as free as in the congenital form. Congenital Dislocations of Other Joints. — Congenital dislocation of the knee is not frequent, only ninety-eight cases having been reported. It is regarded by some authors as a genu recurvatum or a hyperextension, rather than a displacement. It is, however, to be looked upon as a true dislocation, and is frequently double.^ The leg is usually displaced for- ward, so that the condyles of the femur project in the popliteal space. Congenital Dislocation of the Patella. — This is also infre- quent. The displacement is usually outward, as in one of the varie- ties of traumatic dislocation. In this connection may be mentioned the rare occurrence of congenital absence of the patella, which can be recognized by the knee being broad and flat and very much impaired in function. Congenital Dislocation of the Shoulder. — This is very rare. In the majority of cases reported as such it was due to relaxation of the joint (following the form of paralysis described on page 437) owing to tearing of the upper roots of the brachial plexus (Fig. 271). In others it is due to separation of the epiphysis. Coxa Vara. The attention of the profession was first, called to this interesting deformity by E. Miiller ^ in 1888, and the name coxa vara given to it by Hofmeister in 1894. It may be defined as a bending downward (Fig. 445) of the neck of the femur sufficiently to cause symptoms. The neck may form a right, or even an acute, angle with the shaft. CHnically it is seen most often in males during adolescence and less frecjuently in children. ^ "Zeitschrift fur orthopedische Chirurgie," vol. vii. DEFORMITIES. 649 It is best divided into the following forms : 1. Congenital coxa vara. 2. Rachitic coxa vara of childhood. 3. Coxa vara of adolescence. 4. Traflmatic coxa vara. 5. Inflammatory and trophic coxa vara (following osteomyelitis, arthritis deformans, osteitis deformans, osteomalacia). The symp- Fig. 445- — X-RAY OF A Case of Coxa Vara, Taken from the Patient shown in Figs. 446 and 447. Note the downward inclination of the neck of the femur on the side of the coxa vara (right), and the mush- room-hke expansion of the head of the bone. On the left side the epiphj'seal line between the head and the neck and between the greater trochanter and shaft respectively are well shown. toms of all of these forms are the same, the division beinc according: to the age at which it is first observed, and the etiology. The form which requires especial mention in connection with its etiology is the traumatic. This term was first given to it by Sprengel in 1898.^ It follows either a separation of the ci)iphysis or an actual fracture of the neck of the femur in cliildren and young adults. In the case of epiphyseal separation, as well as of fracture of the neck, the ' "Archiv fijr klinische Chirurgic," vol. Ivii. 6;o THE EXTREMITIES. head of the bone becomes flattened or mushroom-hke and the neck bent downward so as to he below the level of the trochanter. The injury may be so slight as to be overlooked, until the resulting deformity appears. Reference has been made to the symptoms of fracture of the femoral neck in children (page 499) which may result, according to Whitman,^ in coxa vara. The diagnosis of coxa vara of whatever origin depends upon the follo-^ing chnical findings : 1. The History. — The early symptoms depend upon the cause. In those due to trau- ma there may have been a slight or severe injury, followed by vague pains in the hip, and later the appearance of the deformity. In others there is a histor}', in adolescence, of gradually increasing pains in the hip and discomfort on walking. 2. Tlie Symptoms oj the Deformity. — [a) Limitation oj Motion. — This is most marked in the direction of abduction and in- Avard rotation, both of which are greatly re- stricted. The limitation of abduction is due to the pressure of the trochanter against the ilium, when the limb is abducted. The Kmi- tation of inward rotation is due to the fact that the neck of the femur is not only bent downward, but also backward in the major- ity of cases. (h) Attitude oj tlie Limb. — The hmb is everted and adducted, except when the neck is bent forward. Under the latter conditions it is inverted. (c) Shortening.— This is one of the most characteristic signs. There is genuine short- ening as measured in the usual manner (Fig. 447). The trochanter lies above and a httle behind the Roser-Xelaton line (Fig. 447), and is more prominent upon the side of the deformity. In children the shortening may be slight. There is also marked atrophy of the muscles of the thigh and gluteal region. ^ "Annals of Surgery," 1900. Fig. 446. — Typical Position in a Case of Coxa Vara Adoles- CENTIUM. This is the anterior view of the case shown in Figs. 445 and 447. A, A, Location of anterior superior spines of the ilium; B, B, the black point above these letters indicates the mid- dle of the patellae; C, C lower borders of internal malleoli. Note the short- ening of the hmb, the external rota- tion or eversion, and the prominence of the left trochanter. DEFORMITIES. 651 (d) Gait and Pain. — The patient stands upon the toes of the dis- eased side, the hmb being adducted and rotated outward. He limps, and if the affection is bilateral there is a distinct waddhng gait. There is also more or less pain in the hip, rarely in the knee, when walking. The Trendelenburg sign is also well marked in unilateral cases. 3. X-ray Examination. — This shows the extent of the deformity. The bend is most frequently downward and backward, less often downward and forward, and least often simply down- ward. The mushroom-like flattening of the head is also well seen. Differential Diagnosis/ — It is al- most impossible to differentiate cases of traumatic coxa vara from those of true coxa vara of adolescence except from the history. If the trauma has been slight, even this may be mislead- ing. From Tuberculous Coxitis. — Coxa vara never gives rise to abscess forma- tion, while this is of frequent occur- rence in tuberculous coxitis. The on- set of coxa vara is more abrupt and acute than it is in the majority of cases of tuberculosis of the hip-joint. It is a self-limited disease, and sooner or later a- spontaneous cessation of the acute symptoms may be confidently ex- pected, while the opposite clinical ten- dencies characterize tuberculous cox- itis. This, like tuberculous processes in other parts and organs of the body, is generally attended by a slight rise in the evening temperature, while the temperature in coxa vara remains normal. In the great majority of cases, tuberculous coxitis is a disease of cliildliood, and begins, in the large 'The author has taken many of the differential diagnostic points from the article of Dr. Nicholas Senn. Fig. 447. — Posterior View of a Case of Coxa Vara Adolescentium. Same case as shown in Figs. 445 and 446. T, The arrow points to the prominent tro- chanter on the side upon which the coxa vara was situated; R, R, Roser-Xelaton .Une. Note how the trochanter Hes above the Roser- Nelaton line on the side of the coxa vara. Also note the shortening and aversion of the limb. 6S2 THE EXTREMITIES. proportion of instances as a primary osteal affection in the proximal end of the femur. Its onset is insidious. The pain is referred to the injflamed joint, and radiates along the course of the obturator nerve to the inner condyle of the femur. During the early stage of the disease, the thigh is slightly flexed, abducted, and rotated outward. Nocturnal muscu- lar twitching is almost a constant symptom; this is something which is never found in coxa vara. In tuberculous coxitis, muscular rigidity fixes the joint at an early stage. All movements are productive of pain, and light blows against the condyles invari- ably aggravate the pain. Tenderness, such a marked clinical feature in tuber- culous and other inflammatory affections of the hip-joint, is never found in coxa vara. Shortening and outward rotation of the limb belong to the later stages of tuberculous coxitis, while in coxa vara they may even precede the painful or acute stage of the disease, and the shortening is always one of its early manifestations, usually combined with outward, and, in exceptional cases, with inward rotation of the hmb. As a final diagnostic test in doubtful cases, the employment of the Rontgen ray will en- able us to differentiate between the two affections (Fig. 444). In coxa vara, the downward bending of the femoral neck is almost characteristic, while in tuber- culous coxitis the :r-ray picture will either show the existence of a destructive pro- cess involving the proximal end of the femur, frequently complicated by coexist- ing or consecutive disease of the acetabulum, or it will show no change in the angle of the neck. Bilateral coxa vara is of more frequent occurrence than bilateral tuberculosis, in the relative proportion with which these two diseases are encountered in practice. Muscular atrophy is more marked in tuberculous coxitis than in coxa vara. Arthritis Deformans. — The differential diagnosis between coxa vara and arthritis deformans, called senile coxitis, where it affects the Fig. 448.- -Double Genu Valgum (Fow- ler). DEFORMITIES. 653 hip-joint, presents fewer difficulties. Coxitis senilis is a disease of advanced life. Cases of senile coxitis are seldom met with in persons less than forty- five years of age. In senile coxitis, the angle of the neck of the femur is not diminished. Arthritis deformans is not infrequently a polyarticular disease, while coxa vara is an affection which is only met with in the hip-joint. In senile coxitis, the head of the femur occasionally becomes elongated, but during the later stages the upper surface is deprived of its carti- laginous covering, and the exposed underlying bone becomes hardened and is pohshed by the limited movements of the joint. There is no pain, no cracking, or rough- ness ehcited by joint motion as in well-advanced cases of senile coxitis. The shortening of the limb in senile coxitis is not caused by bending downward of the neck of the femur, but by loss of tissue of the head of the femur and the upper seg- ment of the acetabulum. Genu Valgum (Knock-knee). This may occur as a symp- tom of general rachitis in early life when the children first learn to walk (page 590). It also ap- pears during adolescence (/. e., between the twelfth and eight- eenth years) as a static de- formity. Genu valgum may also follow fractures of the femur and paralysis of the leg and thigh muscles. The diagnosis in these varieties is not difficult. The chief features are: 1. An inward angular deformity (Fig. 448) at the knee-joint, which disappears when the leg is flexed upon the thigh. 2. When the leg is thus flexed the internal condyle is seen to be relatix'cly prominent. 3. The gait is quite characteristic. It is a rolling one, the leg lacing thrown outward with each step forwartl. Fig. 449. — Bow-legs (Moore). 654 THE EXTREMITIES. The differentiation of either genu varum rachiticum or adoles- centium from the paralytic or traumatic forms presents no difficulty. The presence of atrophied and paralyzed muscles will ehminate the paralytic form (Fig. 448), and the histon,' of an injury will exclude the form following fractures of the femur or tibia or laceration of the internal lateral ligament of the knee. Genu Varum (Bow-legs). In this deformity the femur and tibia form an outward angle (Fig. 449). Like the corresponding inward angular deformity (genu valgum) it is most frequently the result of rachitis, and is one of the earliest evidences of the latter. It is seen even in children avIio have never attempted to stand. In later life a similar deformity appears as a symptom of osteitis deformans (page 592). The distinctive features of the rachitic genu varum are: (i) The gait is a waddling one, the feet and knees being wide apart and the toes usually inverted; (2) the deformity is most marked in the femur and tibia when one is in the standing position (Fig. 449). In the minor- itv of cases the bowing is either an- gular and chiefly in the lower third of the tibia, or there is a forward curving of the tibia and sometimes of the femur also. To the latter class the term anterior bow-legs is apphed. Deformities Caused by Anterior Poliomyelitis. These are generally of three var- ieties: {a) Those due to trophic changes, resulting in atrophy of the bone with marked shortening of the hmb (Fig. 450). In these cases there is an increased liability to spontaneous fracture. (6) Those re- sulting from muscular paralysis. These either cause contractures or flail joints, (c) Dislocations, either complete or partial. The first class are not difiicult to recognize, the only other causes Fig. 450. — Marked Shortening of Right Lower Extremity Following Anterior Poliomyelitis in Intancy. Note the pes equinus paralyticus position of the foot. DEFORMITIES, 655 of a shortened limb being a fracture through the epiphyseal cartilage or a resection of the ends of one of the long bones. In both, the history, the absence of motor paralysis, and the other signs of poliomyehtis Fig. 451. — Talipes Equinovarus (Moore). will clear up the diagnosis. The deformities in the second class are the result of paralysis, which, as a rule, does not involve all of the^ muscles of the limb. In the thigh the muscles usually involved are those of the anterior and internal groups, re- sulting in a flexion of the hip and knee (Fig. 450). There is often a subluxation of the tibia backward and a marked genu valgum. In some cases there is hyperextension of the knee, combined with fiat-foot. The most common deformities of the foot in their- order of frequency are (a) tahpes ecjuinovarus; (b) calcaneo- valgus; (c) pes calcaneus or pes cavus. The third form of infantile paralysis de- formities is not frecjuent. The most com- mon is dislocation of the hip. The diagnosis of all of these paralytic deformities depends upon the recognition of the primary disease, viz., ]joliomyelitis anterior. Tlie onset is usually sudden, the paralysis is of the flaccid type, there is marked muscular and often bone atrophy, the paralysis usually affects only one limb and is not hemiplegia. The reaction of degeneration is also present. -Talu'ks Equinu.s (.Fow- ler). 656 THE EXTREMITIES. Fig. 453. — Talipes Calcaneus (Fowler). Talipes Equino- varus (Club-foot i. This is a deformity of the foot which is readily recognized. The majority of cases are of congenital origin. In a small number, however, the condition is an acquired one, usually secondar}^ to an infantile paralysis. The foot is inverted and rotated upon its axis, so that the outer border of the sole touches the ground (Fig. 451) and the toes point inward. The front part of the foot is at the same time de- pressed. The head of the astraga- lus and cuboid can be seen to pro- ject just beneath the skin, while the inner malleolus cannot be felt. The congenital can be differ- entiated from the paralytic form by the presence of paralysis of the muscles on the anterior and external surface of the leg in the latter. The tendo Achilhs in the acquired form is found to be very tense. Talipes Equinus. In this deformity the heel is dravTi up, and the toes point down- ward. It may be of congenital or acquired origin. The former is not common, the usual combina- tion being that of equino-varus or club-foot. An acquired talipes equinus may follow (a) infantile paralysis, (b) disease of the ankle- joint, (c) any form of spastic par- alysis (hemiplegia, etc.), (d) frac- tures or diseases of the hip- or knee-joints. It varies in degree. In moderately severe cases the patient walks upon the ball of the foot, i. e., upon the heads of the meta- tarsal bones. The toes are hyperextended (Fig. 452). Callosities and bursse frequently form over the ends of the metatarsal bones. In milder Fig. 454. — Typical Flat-foot (Gillellc). DEFORMITIES. 657 cases, when the patient attempts to walk the weight is borne mainly upon the front half of the foot. In the most severe forms the weight is borne entirely on the dorsal surface of the metatarsals and toes, the sole of the foot being directed backward. Talipes Calcaneus. This is comparatively rare as a congenital affection. It is usually an acquired deformity, and follows an infantile paralysis of the mus- cles of the calf of the leg. The front part of the foot (Fig. 453) is drawn up by the muscles of the front of the leg. The patient walks upon the heel, and the gait is inelastic because the spring of the foot is absent. It is generally associated with a tal- ipes valgus or talipes cavus. Talipes Cavus. This is a condition in which the arch of the foot is increased so that the front of the foot approaches the heel (Fig. 454). It is rarely congenital. In the majority of cases it is an acquired deform- ity, the result of an in- fantile paralysis. Talipes Valgus. This i-s one of the more common con- A 1; Fic. ^55. — A, Impression of Normal Foot; B, Impression of Flat-foot. genital deformities of the foot. The arch of the foot is entirely lost, the sole being everted so that it touches the ground at all points, and finally the front of the foot is turned out (abducted). Acquired talipes valgus differs from an acquired flat-foot by the absence of a distinct dropping of the arch of the foot. Its most common cause is an infantile s|)inal paralvsis. It is much less painful than flat-foot. Flat-foot (Pes Planus). This affection is most common during adolescence, and is essen- tially a yielding or lowering of the arch of the foot. The instep is 42 658 THE EXTREMITIES. unable to support the weight of the body. It may develop either gradu- ally or acutely. It may be due to a number of causes: (a) To occu- pations requiring prolonged standing, like that of waiters, etc. ; (b) to rheumatism, es- pecially gonorrheal; (c) after Pott's frac- ture (Fig. 345); (d) as a compHcation of rachitis; (e) weakness of the muscles of the great toe and head of the first metatar- sal bone ; (/) improperly made shoes, with low insteps; (g) rapid growth or in- crease in weight; (h) infantile or spastic paralysis. Clinically it can be readily recognized if close attention be paid to the normal condition, and also to the fact that not every painful affection of the foot is due to '"rheumatism." There are two forms clinically: (i) Flexible flat-foot or weak- ened foot, where the- flattened position is assumed as soon as weight is put upon the foot; (2) rigid or true flat-foot, in which the deformity is permanent, owing to alterations in the structures of the bones. The condition is more bilateral than unilateral. The diagnosis depends upon noting any lowering of the arch of the foot when the patient bears the weight upon it. x^n impression of the foot should be taken by allowing the pa- tient either to step upon card- board blackened with cam- phor smoke, or by covering the sole of the foot with oil and having him step upon a sheet of paper, placing the extra weight upon the foot. ' A variable degree of pain is present in the neighbor- hood of the scaphoid, and often it is also referred to the leg, knee, back, or hip. In the milder cases it is only noticed when the foot is stepped upon. In the more Fig. 456. — Hallux Valgus (Fowler). ^ Fig. 457. — Appearance of Hand in a Case of Webbed Fingers. The index, middle, and ring fingers are bound together so that they can only be distinguished at their distal ends. DEFORMITIES. 659 severe, the pain is constant, and independent of bearing the weight upon the feet.' There is also some tenderness over the most painful points, viz., over the scaphoid, outer border of the foot, center of the heel, front of the foot, and behind the inner malleolus. At times the pain and tenderness seem so distinctly localized, that an inflammatory focus is thought of. Inflammation of the tendon-sheaths of the peroneal and tibial tendons, in the shape of elongated soft swelhngs along the front and sides of the ankle, are often the symptom for which the physician is Fig. 458.- -X-RAY OF Antero-posterior View of Hand, , SHOWING Needle in Situ. Fig. 459. — X-RAY OF Lateral View OF Hand, showing Needle in Situ. consulted. In very acute cases the foot is held abducted through contraction of the peroneal muscles. The foot is often swollen, and becomes so rigid that the front of the foot cannot be adductcd actively or passively as much as it can normally (Lovett). There is also limitation of motion in the ankle-joints. When the patient walks, the feet are everted, and the weight is borne ujjon the inner side of the foot. There is a lack of elasticity in the gait. In children there is but little pain on walking. The physician is often consulted Ijecause the cliild tires easily, or com])lains of pain in the legs, back, or hips. Rigidity is rarely present. The chikl cannot 66o THE EXTREMITIES. balance itself well, and falls frequently. There is usually a greater degree of flattening than in adults. Metatarsalgia (MORTON'S Disease). This condition is characterized by frequently recurring attacks of severe pain, which usually appear between the third and fourth or Fig. 460. — X-RAY OF Gunshot Wound of Hand. Showing bullet embedded on metacarpal bone of thumb. fourth and fifth toes while the patient is walking. The anterior arch of the foot, formed by the heads of the metatarsals, is often relaxed or flattened, so that the heads of the second, third, and fourth meta- tarsal bones are on a lower level than normal. The arch of the foot is often flattened. The toes are often rigid, and dorsal flexion of the foot may be limited. DEFORMITIES. 66 1 Hallux Valgus. This is a deformity of the great toe, in which the phalanges are pushed outward and form an angle with the head of the metatarsal bone, which becomes enlarged. The bursa lying over the latter may become inflamed from time to time, and be present as a tender, soft swelhng (bunion), which becomes acutely inflamed at intervals. Congenital Deformities of the Hands. Cluh-hand is usually associated with other deformities. The hand is flexed and drawn over to the radial side. Webbed fingers (syndactyhsm) involves two or more fingers. The union extends a variable distance to the tips (Fig. 457). It is often associated with a lack of development of the bones of one or more fingers. Supernumerary digits (polydactyhsm) are also congenital. They are generally symmetrical and involve hands and feet (Fig. 457). Usu- ally there is but a single digit in excess, on the side of the little finger or httle toe. The development may be complete or more or less i-Tiperfect. Foreign Bodies in the Hands or Feet (Figs. 458, 459, 46o). Various foreign bodies may penetrate the integument and remain embedded in the subcutaneous or deeper tissues. The most frequent locations of these are the hands and feet, and the usual substances, needles, portions of a bullet, bits of glass, etc. The most reliable method of locating these is by the use of the .v-ray. One should never depend upon a fluoroscopic view of their location, care being taken to take skiagraphs in two directions. This method is to be especially recommended for needles. CHAPTER VI. DISEASES AND INJURIES OF THE SPINE. SPINA BIFIDA. This congenital deformity of the spine occurs most frequently on the posterior aspect, less often on the ventral or anterior surface. Var- ious combinations occur as the result of a non-closure of the neural arches. These are: Rachioschisis. — This is due to a complete or partial absence of union of the medullary canal. This is the most severe form. There is a defect of normal skin in which an open depression exists, at the base of which a soft red band of vascular tissue is found, which repre- sents the cord. It rests upon a thin reddish membrane, which repre- sents the pia mater, which is continuous on both sides with the skin. The dura and arachnoid he beneath it, and pass over into the subcu- taneous tissue. The arches are present as short stumps, and the bodies are greatly deformed. Myelocele or Myelomeningocele. — The conditions of the bones are the same as in the first form (rachioschisis), but, owing to the accu- mulation of fluid between the membrane on the ventral side, the cord and its coverings on the dorsal aspect are pushed out and form a visi- ble thin-walled sac. The cord hes upon its inner side and is closely adherent to it. As in the first form there is a defect of skin, thus favor- ing infection. Myelocystocele. — This is a smaller or larger sac whose outer covering is thin, but otherwise unchanged. The innermost layer is composed of greatly thinned cord. Between it and the skin are found two thin vascular layers, representing the pia and arachnoid. This form of spina bifida is the result of the accumulation of fluid in the central canal, and the dilated cord is covered by pia-arachnoid and skin. The dura does not take any part in the coverings of this or the two preceding forms. Meningocele. — In this form a cyst with a narrow pedicle is found. The sac is either composed of pia-arachnoid, with fluid in the subarachnoid space, or only of dura, with fluid in the subdural space. The cord seldom participates in the formation of the sac. When it does the condition is known as a myelocele. 662 SPINA BIFIDA. 663 The diagnosis 0} a spina bifida itself is, as a rule, not difficult. The majority occur on the posterior aspect of the spine in the lumbo- sacral region (Fig. 461). Rachioschisis and myelomeningocele can be recognized by the defect in the skin. In both, deformities as well as paralyses of the extremities are frequently found, with or without in- volvement of the sphincters. The third and fourth forms, viz., myelo- cystocele and myelomeningocele, are covered by normal but thinner skin. The first named is often associated with other deformities, such as Ftg. 461.— Side and Front Views of a Case of Extensive Spina Bifida. hydrocephalus, club-foot, etc. These two forms can only be distin- guished when the sac is opened. In a meningocele one finds a smooth serous inner wall, while in a myelocystocele there is a red- dish-brown vascular tissue which leads into the open cord. ]\Ienin- goceles are rarely accompanied by symptoms of ])aralysis. When pressure on the tumor causes the fontanelles lo bulge it is more likely to be a myelocystocele. Myelomeningoceles are usually found in the saci"uni, while myelo- cystoceles may occur an\\\here. 664 DISEASES AND INJURIES OF THE SPINE. INJURIES OF THE SPINE. In the examination of a patient suffering from an injury to the vertebral column either recent or of long standing, the following routine will be found useful: 1. How was the injury received? 2. What is its probable nature? 3. Does evidence of compression or destruction of the cord or its nerves exist? 4. At what level did such injury occur? 5. What are the objective evidences of such injury, exclusive of that of the cord? General Consideration. — Before discussing spinal injuries in detail a brief resume of our present knowledge of their pathology and the chief points in spinal locahzation will be taken up. Pathology of Injuries of the Spine. — Injuries of the vertebrae usually occur in adult hfe and in an indirect manner. The direct modes of injury affect the arch, while the indirect involve the body of the vertebra. Most frequently the indirect are the result of a sudden bending forward (flexion) of the spine. Only in a small proportion of cases do hyperextension or lateral or rotary forces play a role. Pure fractures are quite rare. ' In the majority of cases the injury is a combination of a fracture and a dislocation. Such fracture dis- locations are most apt to occur between the tenth dorsal and second lumbar vertebras. True dislocation without fracture is most apt to occur in the cervical region. The part most frequently fractured is the body of the vertebrae. The general statements on page 438 in regard to fractures of the bones of the extremities hold true for those of the vertebrae. Com- pression fractures are more common, however, than in the case of any other bones except those of the tarsus (Fig. 358). The compression may be so extreme that the upper and lower intervertebral discs may be brought into contact with each other, the substance of the bone being partly compressed and partly displaced upon the sides or behind into the spinal canal (Fig. 452). With this may be associated fractures of the arches, spinous and transverse processes, or extensive tears of the ligaments. By dislocation of a vertebra is meant an injury in which the adjoin- ing articular processes on one or both sides have been partly or com- pletely separated from each other. If a fracture of the body or its arch has occurred at the same time in a true dislocation, such a INJURIES OF THE SPINE. 665 fracture can be deemed unessential to the production of the dislo- cation. The normal range of motion between adjoining vertebrae is in two axes, one vertical in the median plane, and the other horizontal, pass- ing through the posterior part of the disc. There are two modes or varieties of dislocation, viz., (a) by abduction, which includes complete or incomplete unilateral dislocations forward or backward, and (b) by flexion, which includes bilateral dislocations forward or backward. The spinal cord terminates at the lower border of the body of the first lumbar vertebra. It is made up of a number of segments, similar and partly independent, which corre- spond to the vertebral bodies and each pair of spinal nerves. Ever}' segment possesses motor, sensory, and reflex functions besides vaso- motor, visceral, and trophic activi- ties. The spinal cord may be in- jured directly (a) by the displace- ment of a fragment; (b) by the pressure of a dislocated vertebra; (c) by a blood-clot; (d) by an in- flammatory exudate; {e) by elonga- tion; (/) by being penetrated by a fragment (rare); (g) by being pene- trated by a cutting instrument (stab wound) or a bullet. In one case ob- served by the writer a piece of tin was thrown horizontally in such a manner as to enter between the atlas and skull and sever the cord. In fractures, the cord is usually caught between the anterior ])ortion of one fragment and the posterior portion of another (Fig. 462). The dura is seldom torn, the cord being ])ulpiried at the moment of the injury. Hemorrhage may occur either around llie cord (extra- dural), or within its substance (hematomyelia ). The blood in the former case spreads up and down in the canal, and thus compresses llie cord. In hematomyelia the hemorrhage may lake ]jlace into the gray Fig. 462. — Fkactl'ke-dislocation or Spine, SHOWING Crushing of the Cord (Guy's Hospit:il Miisi-um). 666 DISEASES AND INJURIES OF THE SPINE. matter alone and be limited to a few segments, or, if the lesion is more severe, the hemorrhage extends into the white columns. If the patient survive, the absorption of the clot leaves cavities which fill with scar tissue. The elements of the gray matter are thus permanently destroyed. Apparently most of the cases of injury to the neck which recover after having presented symptoms of severe injury to the cord are cases of hematomyelia. Spinal Localization. A knowledge of the functions of the various spinal cord segments is absolutely essential to the diagnosis of surgical lesions of the cord. Such cord lesions may follow (a) the pressure of a fragment in fractures of the vertebra; (b) the pressure of a dislocated vertebra; (c) hemorrhage into or around the cord ; (d) a stab or gunshot wound ; (e) pressure of a tumor or inflammatory exudate. Cord lesions cause: (a) irritation; (b) partial destruction, or (c) complete destruction. (a) Irritative lesions cause hyperesthesia, pain, spasms, rigidity, and increased reflexes. (b) Partial Destruction of a Segment. — This is seldom strictly uni- lateral. If only one lateral half of the transverse cord section is in- volved, as occasionally occurs after stab wounds, the complex symptom known as Brown- Sequard paralysis develops. There is complete loss of power on the same side as the lesion in all parts below that point. There is also a shght loss of power below the lesion upon the opposite side. Anesthesia is complete on the side opposite the lesion, below its level. There is a band of cutaneous anesthesia upon the same side as the lesion which marks its exact level. It varies vertically accord- ing to the extent of cord destroyed. There is a band of hyper- esthesia above and below the band of anesthesia on the paralyzed side. On the opposite or anesthetic side, there is also a band of hyperesthesia a little below the level of the hyperesthetic band of the paralyzed side. The reflexes are increased below the lesion on the paralyzed side, but are abolished at the level and throughout the vertical extent of the lesion. The muscular paralysis in these partial cross lesions is usually of a spastic character, because the reflexes are preserved and increased as just stated. In late cases of partial cross-lesions, the rigidity and spastic features INJURIES OF THE SPINE. 66' are well developed (Church). The lower limbs are either held rigidly extended or less frequently, flexed. Contractures finally develop (Fig. 463). (c) In total destruction 0} the cord the symptoms are in general: (i) Paralysis of the muscles supplied by the segment involved and of all muscles represented in the cord below the lesion. This results in a paraplegia. (2) Anesthesia in the area of skin supphed by the seg- ment and in all parts below. This is really the best guide to the level of the lesion. (3) A zone of hyperesthesia at the upper border of the area of anesthesia. In the trunk total transverse lesions of the cord produce an anes- thesia whose upper limit is horizontal, while le- sions of the nerve-roots cause anesthesia or hy- peralgesia which follows the direction of the in- tercostal nerves and spaces, (d) The reflexes furnish very valuable evidence not only as to the upper level of the cord lesion, but some- times as to its vertical extent. Complete destruction of the cord extini^iiishes all reflexes below the level involved, while partial division causes an enfeehlement of the same reflexes, which later on is succeeded by an exaggeration of the same. The absence of one or more of these increased reflexes in such a case points to the level of the lesion. Again, the upper level of abolished reflexes usually coincides with that of anesthesia, and cither one enables us to locate the lesion. (e) Trophic Dislurhances. — Tlie extent of muscular atrophy depends upon the vertical dimensions of a lesion. Thi' musdes innervated from the cord above and below the destrucli\e process are spared, and regain their nutrition and electrical reaction. The normal galvanic Fig. 463. — Marked Paralytic Contractures of the Lower Ex- tremity Following Compression Myelitis, due to Frac- ture OF THE Spine. 668 DISEASES AND INJURIES OF THE SPINE. response gradually disappears in the atrophied muscles and is re- placed by the reaction of degeneration. In acute destructive lesions and cord hemorrhage, acute bedsores may form in a few hours over the sacrum, heels, malleoh, and trochanters (Fig. 369). (/) Vasomotor Changes. — The paralyzed limbs are warmer than normal, and there is distention of the subcutaneous veins. Priapism is a very common sign of such vasomotor paralysis in lesions of the cervical segments. In addition the latter often cause flushing and perspiration on the side of the neck and face and may reduce the heart-beats to forty or less per minute. Dorsal lesions are sometimes attended by a persistently rapid pulse. ig) Visceral Symptoms. — There is usually disturbance of the anal and vesical sphincters. When their reflex centers in the lumbar cord are destroyed the sphincters are completely relaxed, and incontinence results. If the lesion is abo^'e their spinal center only voluntarv con- trol is lost. This results in retention of urine and feces. The disten- tion of the bladder may become so extreme that overflow occurs, resulting in the constant dribbhng of urine. This latter condition is called incontinence of retention. Cystitis and pyelonephritis almost invariably follow the continued and unavoidable use of the catheter in these cases, despite every pre- caution to prevent infection. The retention of feces present in the early stages often gives way to incontinence. Intestinal obstruction, of the variety known as adynamic ileus, may develop immediately after an injury of the spinal cord. It may be temporary or permanent, the latter invariably resulting fatally. This paralysis of the intestinal musculature is the result of the involvement of the splanchnic nerves. The clinical picture in such cases resembles that described under intestinal obstruction (page 277)- Acute gastric dilatation may also develop as a complication of spinal cord injuries. A study of the accompanying table of symptoms^ (pages 669 to 675) will be found extremely useful in the diagnosis of the level of a cord lesion. The table shows the clinical signs in cases of disabling, but not absolutely destructive, cord lesions. If the entire cross-section is absolutely destroyed the symptoms are the same, but there is com- plete absence of muscle reflexes below the lesion. ^Wichmann: "The Relations of the Spinal Nerves and Segments," Berlin. 1900. INJURIES OF THE SPINE. 669 _- ~-.^_^ . ^^^^ • — .^ • x-o J ^ ^~---- »-i ■*-* 2 s a si's ^ -^ 0^ ^^, .2 lljll ^^^^^^^\ >> o^a \ ^^^^^^^ \s \ i. 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O S § .3 >.§ ex- ' of rnal pes- N _^ 1- ^ , •sfll 'S .S 3 a >>62 ^^ H 5 u _^^^^^^^ ^ ■1 ^^^^^^^^^^^ ^ft 2 -"f^ s-s ^^^^ W 3Ji-Sg^ Q«^ U„ H [3 a) .S a "t; E tu tH Pi ^ ^ e S 3 5- a 3 T3 tn s^ . . 3 3-B 1^ ^ oJ rt i, m l^ '^ ^ oi d ^ p 1— 1 3 J:! 3 < pI] ■ M-. +J cfi V D, o§ ■V en u 'f^ S9 -a . J 11 >» 1^ =3'E sl (S 3 rt 3 g -g _a; rt _aj ^ -55 JS S 1-5 Oi ti-. eu ^4 Cd U > u 1 -^ .2 pa ^ H ^ iJ 1^ z Z rt S cit c w ^Xi •-Q . J3 5; a HE K E "E w 3 3 3 ^c^ J uj INJURIES OF THE SPINE. 673 .ss £ I- S ^ M > ° & — ^ « G cs o te i; . o ft S 0-3 O'^ s . §•2 oiixi ft ftTj ft g ^ S-= E " ^ ^ S"o O <; d to o a a a. ^ O H j •S in >-. fl.t! O-^ C . 0,^ m ^ Ji « S^ g g OJ o o^ >^ >>T-, w u t-, 3 c r! ■g^^^ga^g d. <<;foO!=li-! 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The sensory, motor, trophic, and reflex symptoms are the same as follow division of the indi^ddual nerve-trunks. In partial lesions, sensation may be but slightly disturbed when motion is quite lost. Increased reflexes are not encountered. The lowest portion of the cauda is usually involved, and the lesions cease at some definite upper level. ]Most cord lesions, on the other hand, are Hmited in vertical extent, and the reflex and trophic disorders are confined to the corresponding body segments. In the examination of an individual, for the purpose of making a diagnosis of an injury of the spine and spinal cord, the various con- ditions which require consideration are: (i) Fractures; (2) dislocations; (3) hematorachis and hematomyelia; (4) concussion of the spine; (5) traumatic spondylitis. "^ Fractures of the Spine. A true fracture of the vertebral column without accompanying dislocation is so infrequent that the term "fracture-dislocation" would be more appropriate. Their diagnosis can be best considered in con- nection with the individual regions. Of the Upper Two Cervical Vertebrae (Atlas and Axis). — Three classes of cases occur clinically, viz. : (a) Those in which death is immedi- ate, and no diagnosis can be made as to whether fracture or dislocation existed. (&) Those in which death occurs, weeks to months after the injury, as the result either of a secondary' myelitis or after a sudden movement of the patient. In the absence of paralysis a diagnosis cannot be made in these cases, (c) Those in which no symptoms exist, and the nature of the injury often remains unrecognized. These last named cases are usually diagnosed as sprains. They complain of pain in the neck and it is held rigid. It was formerly thought that practically all of the cases of fracture or dislocation of the atlas or axis belonged to the first group, i. e., where death was immediate. According to Gurlt, these constitute the min- ority. In the second group, where the patient survives and the symptoms of secondary myelitis appear, the diagnosis can be made from the latter, and is occasionally confirmed by the palpation through the mouth of the displaced vertebra at the level of the bony septum. In some cases the paralysis involves all of the parts below the fracture. I^7^RIES OF the spixe. 677 In others there is only partial paralysis, and, in one case, only a shght diminution of sensibility in the left arm. From the Third Cervical to the Second Dorsal Vertebra In- clusive. — In this region one must distinguish fractures of the body from those of the arch. If the latter occur, there is crepitus or irreg- ularity of the spinous processes. In respect to the latter, it must not be forgotten that the third and fourth cervical spines normally lie quite deeply. In fractures of the body an abnormal prominence can often be felt through the pharynx. The position and mobility of the head vary greatly. It is held rigid in the majority of cases, the shoulders being dra\Mi up and the neck shortened. In some cases the head can be moved freely to either side, but not forward or backward. As a rule, symptoms of pressure upon the spinal cord appear early. Thev may be due to (a) a hemorrhage into or around the cord, or (b) compression by a fragment or displaced vertebra. If no spinal symptoms occur a differential diagnosis can . only be made by an x-ray examination, and the fact that the symptoms persist for a longer period. If the third to fifth cervical vertebree are broken, death either occurs from paralysis of the phrenic nerve or the diaphragm acts only two' or three times a minute, accompanied by a very slow pulse. The extent of the peripheral paralysis accompanying compression of the cord in this region varies. Paralysis of the arms is not as constant as one would expect. Often the paralysis only extends to the level of the umbihcus or breast. The paralysis of the arms is quite often absent. In some cases the paralysis of the arms may appear upon the day after the accident, or even later. It may involve only one arm or a single group of muscles. In some cases there is great dyspnea, especially during expiration, as a result of paralysis of the intercostal and abdominal muscles. In other cases there is marked difficulty in speech and swallo\Aing. There may be paralysis of sensation or of motion alone. Hy- peresthesia of part or all of the arm is at times observed, as well as tonic and clonic spasms. Other symptoms of injury to this region are vasomotor changes in the face and neck, priapism, and a high temperature. In rare instances the vertebral artery has been torn, a large clot forming between the muscles of the neck. In some cases the x-ray has proved to be of great -Calue. The question as to whether the cord symptoms are due to compression of a fragment or of a dis- 678 DISEASES AND INJURIES OF THE SPINE. located vertebra, or whether they are due to hematomyelia, will be considered later (page 682). Fractures from the Third to the Twelfth Dorsal Vertebrae. — The diagnosis of fractures in this region is not very difficult. The arch is rarely involved. Usually the bodies (Fig. 462) of one or more vertebras are involved with direct compression of the cord. In the majority of cases the condition can be recognized (a) by the symptoms of spinal cord compression plus (b) the local evidences of injury. In some cases the compression symptoms may exist without a discernible deformity, and again there are instances where the gibbus or angular deformity is quite marked and yet no paralysis, etc., exists. The spinal cord symptoms may, as in the case of injuries higher up, be due to the compression of a blood-clot (page 681). As a rule, the arms escape paralysis. In the most typical cases there are (a) paralysis of motion in the lower extremities (paraplegia); (b) paralysis of the bladder and rectum, resulting in retention of urine and feces; (c) anesthesia to the level of the injured vertebras (pages 673 and 674); (c/) paralysis of the abdominal and intestinal muscles. As is the case in all spinal injuries, these are subject to great variation. The motor paralysis may be irregular or even absent. The paralysis of the abdominal muscles causes the breathing to be shallow and dia- phragmatic. The tympanites resulting from the paralysis of the abdominal muscles and that of the intestinal musculature may become so extreme as to cause death from a paralytic or adynamic ileus (page 283). Locally the diagnosis of fractures in this region is greatly aided if an angular deformity or a distinct hiatus be found. The spines may be abnormally separated or prominent, or may crepitate. This can be best elicited by passing the finger along the spinous processes. The majority of these patients die from an ascending pyelonephritis in spite of the utmost precautions taken to prevent infection during catheterization. Those who survive often show marked contrac- tures. Fractures of the Lumbar Vertebrae. — Fractures in this resrion decrease in frequency from above downward, those of the last three vertebrae being very rare. Only the first lumbar is frequently broken. The symptoms are chiefly those of pressure upon the cauda equina (page 670), since the spinal cord ends opposite the lower border of the first lumbar vertebra. Paralysis is often absent, and if it is present it re- sembles that of injuries of the 'individual peripheral nerves. The paralysis of the extremities is often unequal or irregular, being con- INJURIES OF THE SPINE. 679 fined to flexors of the thigh and leg. Anesthesia is present in a similar, irregular manner. There are often sharp pains, referred along the course of the peripheral nerves, and paresthesia. Reflexes are either absent or are only feebly present. Muscular atrophy appears very early. Vesical and rectal paralysis is frequently present. Dislocations of the Vertebrae. A dislocation of a vertebra is defined as an injury in which the articular processes of one or both sides have completely separated from each other, accompanied by more or less displacement of the body. The term diastasis is applied by Blasius to those dislocations in which the ligaments and intervertebral discs are so torn, that the vertebrae are separated from each other in front or behind, in a longitudinal direction. They are not displaced on each other horizontally, so as to separate the articular surfaces from each other completely, as in the case of a true dislocation. True dislocations are most frequent in the cervical region, quite rare in the dorsal, and rarest of all in the lumbar region. We usually speak of the upper of the two vertebr£e as the dislocated one. A dias- tasis is most apt to occur between the fifth and sixth or the sixth and seventh cervical vertebrEe. It is often combined with a fracture. Dislocations of the vertebrae are best divided into (a) dis- locations by abduction or rotation, and (b) dislocations by flexion. Under those by abduction or rotation are included the complete or incomplete unilateral dislocations forward or backward, and the bilateral dislocations in opposite directions. The majority of the unilateral are forward, there being only a few cases recorded in which it occurred in a backward direction. Under dislocations by flexion, are included bilateral forward or backward ones. The former is far more frequent, and follows extreme flexion of the neck. There are, as in the case of the unilateral abduction variety, but few cases of bilateral backward dislocations. The diagnosis of this class of injuries of the vertebras, viz., dislocations, is very difficult. The majority of the symptoms are local, and there is little to distinguish them from a fracture. The evidences of displacement are the same, but there is no crepitus as in fracture. The latter sign may, however, be absent even in a fracture. Abnormal mobility might also be of value in (lie dilTercntialion from a fracture, were it not for the fact that the neck is held so rigid that it is impossible to ehcit abnormal mobility or crepitus, and further it is contraindicated to manipulate the spine under these conditions. The neck is held rigid and contracted in both fractures and dislo- 68o DISEASES AND INJURIES OF THE SPINE. cations. The chief diagnostic points of a dislocation are (a) the de- formity; (b) the pain, and (c) the spinal cord symptoms. (a) The deformity can often be recognized by passing the finger along the cervical spines, and also by palpating the transverse processes. The prominence or depression of a spinous process is often quite marked, allowance being made for the fact that one can seldom feel the upper cervical spines even in normal individuals. At times the displaced vertebrae can be felt through the pharynx (Fig. 464). (b) The pain varies greatly, but is generally quite marked, and referred along the course of the affected cervical nerves. Fig. 464. — Fracture and Subluxation ; Cervical Vertebra United (J. Mason Warren collection, Warren Museum) (Walton). (c) The spinal cord symptoms may, as in the case of a fracture, be due to hematomyeha or to the pressure of a fragment or displaced vertebra. The symptoms of compression are absent in a larger number of cases of dislocation, than of fracture; especially is this true of paralyses. If present, they are apt to be less extensive and less marked than in the case of a fracture. Immediate death may occur as the result of phrenic nerve paralysis. In general, however, the paralyses are incomplete, and anesthesia is often absent or unequal. It may be more marked on one side than the other. The paralysis may correspond entirely to that of a peripheral nerve. Paralyses may be INJT^^RIES OF THE SPINE. 68i quite marked and then disappear gradually. In some cases the para- plegia, paralysis of the rectum and bladder, priapism, high temperature, vasomotor changes, and acute decubitus may resemble the same symp- toms following a fracture (page 668). Other nervous symptoms are localized muscular twitchings, general epileptiform convulsions, hyperesthesia, and neuralgic pains in the course of nerves that are compressed. The x-ray may be of some value in confirming the diagnosis, but Fig. 465. — X-RAY OF Normal Adult Spine in Cervical Region. The outlines of the upper four cervical vertebrae are traced in white and marked, i, 2. 3, and 4. respectively. care must be used in interpreting the skiagraph. X-rays shown in Fig. 465 were taken from a normal individual, one without any effort at displacement, and the second (Fig. 466) following extreme voluntary efforts of flexion. They were taken to pro\X' the possil)ility of a normal x-ray resembling that of a dislocation. Hematorachis and Hematomyelia. These conditions are so frequently associated after traumatism that they will be descriljcd together. Meningeal hemorrhage (hem- 052 DISEASES AND INJURIES OF THE SPINE. atorachis) may be extradural or subdural. The symptoms of both are alike. In hematomyelia the hemorrhage usually takes place into the gray matter, but the white matter is not exempt. Both of these con- ditions occur most frequently in the cervical region. The symptoms of hematorachis, when it occurs alone, appear more gradually than do those of hematomyelia. In both, the symptoms depend upon the tension, extent, and location of the clot. The symptoms common to both conditions are the following: (a) Severe pain radiating along the compressed or involved nerve-trunks; Fig. 466. — Pseudo-dislocation of Normal Atlas upon Axis Secured by Protruding Head Volun- tarily Forward. (See text.) (b) symptoms of motor and sensory paralysis; (c) paralysis of the bladder and anal sphincters. The symptoms of hematomyeha are present, as a rule, immediately after an injury, and this is the only feature distinguishing it from hem- atorachis. In traumatic cases the two are so frequently associated that it is almost impossible to make a differentiation. The symptoms are usually most marked at the end of the first twenty-four hours. They subsec^uently improve, and disappear com- INJURIES OF THE SPINE. 683 pletely in four to six weeks. Death may, however, immediately re- sult. Both of these conditions can be distinguished from the spinal cord symptoms following fractures or dislocations by the fact that they develop more gradually, and. further, that they tend to disappear spontaneously within a short time. Concussion of the Spine. This condition has been the subject of considerable dispute ever since Erichsen, in 187 1, pubhshed his treatise on "Spinal Concussion." He described fifty-three cases of spinal injury, received chiefly during railway accidents, which had no external evidence of such injury. The list embraced cases of fracture, hematomyeha, meningitis, hysteria, and neurasthenia. To these he gave the name "railway spine," and this term is extensively employed by lawyers for litigants, even at the present time, to represent an imaginary clinical entity. Oppenheim, in 1880, made a closer distinction between organic injuries and those not marked by histologic changes, and proposed the term "traumatic neuroses" for the latter class. About the same time Charcot taught and demonstrated that the nervous symptoms in these cases, apart from those attributable to organic lesions, were precisely the same as are presented in neurasthenia and hysteria. The latter two conditions may develop after a fright, or after a railway or other accident. They do not, however, differ in any degree in their symptoms or diagnosis from a neurasthenia or a hysteria, which do not follow trauma. Many of the symptoms develop immediately, and are so greatly improved after the settlement of a claim for damages as to have caused them to be termed litigation symptoms. In some cases there is distinct simulation. A celebrated case is that of a patient who claimed to have had a dislocation of the atlas upon th€ axis, and had typical hysterical blindness, and paralyses of motion and sensation, shifting from one limb to the other. X-rays were shown in court which accurately resembled such a dislocation. X-rays were taken of a normal individual (Fig. 468), and it was shown that it was possible to reproduce exactly the sym])toms of the claimant, who had voluntarily thrown the head forward while ha\-ing a skiagraph so as to simulate a dislocation. For the diagnosis of neurasthenia and hysteria the reader is referred to text-books on ner\-ous diseases. Traumatic Spondylitis. This interesting post-traumatic condition was first described by Schede and later by KiimnKJl. ll is in reality a softening of the ver- 684 DISEASES AND INJURIES OF THE SPINE. tebral body following an injury, with the gradual yielding of the body and resultant angular deformity. It follows injuries of the same nature as those which cause the other post-traumatic lesions previously described. The distinctive feature of the disease is the fact that pain along the com- pressed nerves appears months to years after the injury. Accompany- ing these pains there are often paralyses of varying degrees, and the gradual development of an angular deformity, or gibbus, similar to that observed in tuberculous spondyHtis (page 688). In some cases there is a general increase of the curve of the spine. In these cases the diagnosis cannot be made until the deformity or paralysis appears, which occurs a considerable period after the injury. The chief conditions from which it must be differentiated are sim- ulation and a tuberculous spondyhtis. The former is excluded by the objective evidence of the angular deformity or general increase of the curve of the particular region involved. The tuberculous condition is more frequent in early life, accompanied by muscular spasm and abscess formation, and there is less tenderness than in traumatic spondylitis. Gunshot and Stab Wounds of the Spine. The symptoms and diagnoses of both of these forms of injury do not differ from those of other traumatic conditions. Stab wounds usually cause contusion of the cord, producing in the majority of cases a partial paralysis of the Brown-Sequard type (see page 666). Half of the cord is not always severed, but the surrounding degen- eration produces the remainder of the symptoms. In gunshot wounds one finds the symptoms of fracture of the body of the vertebra plus those of paralysis, or the signs of fracture of the arch or spinous process. One cannot tell whether the paralysis is due to the bullet itself or to compression by a sphnter. The x-rsij may be of some aid in this direction. The cord symptoms differ in no manner from those following ordi- nary fractures or dislocations of the vertebrae. They may, however, disappear entirely. Diseases OF the Spine. TUBERCULOUS SPONDYLITIS (POTT'S DISEASE). This and scoliosis are the two most frequent non-traumatic affec- tions of the spine. It rarely involves any other part of the vertebra than its body, producing a gradual disintegration of the latter. In about half of the cases, an abscess is found chnicahy, whose pus gravi- TUBERCULOUS SPONDYLITIS. 685 tates along intermuscular planes, from the original focus. These abscesses usually present externally in certain definite places, according to whether the primary disease is in the cervical, dorsal, or lumbar regions (see below). The destruction of two or more adjacent vertebrae results in the formation of one of the most typical signs of the disease, viz., an angular deformity (see below). A comphcation of the disease Fig. 467. — Method of Examination of the Head and Neck in order to Determine the Presence of AN Inflammatory Affection of the Upper Cervical Vertebra. The surgeon should stand behind the patient, grasping the head between the extended hands, the fin- ger-tips being placed below the lower jaw. The head is then caused to bend forward and backward, elicit- ing pain during these movements. Such evidence of pain is ordinarily not to be obtained in these cases of disease of the atlas or axis, on account of the voluntary fixation of the spine on the part of the patient. is its extension to the membranes of the spinal cord, the resulting pachy- meningitis giving rise to pressure symptoms of varying degree. Primary disease of two verteljral bodies in different, non-adjacent parts of the spine is rare. The two most frequent locahzations of a tuberculous spondylitis are in the twelfth dorsal and first lumbar (dorsolumbar junction) vertebrae, and next in order in the seventh 686 DISEASES AND INJURIES OF THE SPINE. cervical and first dorsal vertebrae (cervicodorsal junction). The most important diagnostic symptoms of the disease are: (i) The reflex rigidity of the spine; (2) the referred pains; (3) the presence of an angular or more gradual deformity; (4) the formation of abscesses; (5) the symp- toms of spinal cord involvement. Of these the presence of the promi- nence, associated with muscular rigidity, and its resultant attitudes and gaits are sufficient to make a diagnosis if the diseases to be described {malignant tumors, frac- tures, etc.) are excluded. I. Rigidity of the Spine. — If the disease is located in the upper cervical region (atlas or axis) the head and neck are either held in a wry- neck attitude or the head is rigidly fixed in the median line. Every eilort to rotate the head or to flex the head upon the neck (Fig. 467) is resisted, or accompan- ied by great pain. The patient attempts to fix the head voluntarily, by supporting the chin up- on the hands. In disease of the lower cervical or upper dorsal region, the chin is held raised, the mus- cles of the back of the neck and of the back itself are contracted and cause the spine to be held stiff and straight. It is difficult for the patient to lean forward or to pick up objects from the floor. In disease of the lower dorsal and upper lumbar vertebras the mus- cles of the back can also be felt to be contracted. The spine is held rigid, and this is most marked when the patient bends over or walks. The gait is characteristic. In the effort to fix the spine the patient will throw the shoulders and head back, and walk by sliding the feet along Fig. 468. — Method of Tapping Head in Order tu Determine Tender Points in Spine. TUBERCULOUS SPONDYLITIS. 687 the floor, so as to move the pelvis and the lumbar spine as little as possible. There is also flexion at the hip (Fig. 469), and the patient steps on the toes. In disease of the cervical and upper dorsal region the patient walks with head fixed in the median Hne, shoulders raised, and spine erect. The rigidity in the dorsolumbar region is best tested by raising the Hmbs while the pa- tient lies prone upon the table. 2. Pains. — The pain of Pott's disease is more often referred to distant points than to the dis- eased vertebra. It is usu- ally referred to the ter- minations of the corre- sponding spinal nerves. In diseases of the cervi- cal region, the pain is re- ferred to the back of the head or neck, or to the mastoid region, or along the arms. In disease of the dorsal and lumbar vertebrae, the pains are referred to the peripheral ends of the correspond- ing intercostal and ab- dominal nerves. It is not uncommon for such patients to complain of stomach-ache, pains like those of a pleurisy, inter- costal neuralgia, or lumbago, or pain in the bladder, etc. The pains are always worse at night, and arc increased by any movements of the spine. In some cases the pain is elicited by tapping upon the head (Fig. 468) or pressing upon the spines. 3. Dejormity. — This, when present, is sufficient to make a diagnosis. In acute cases there is accompanying muscular spasm and referred pains, while in subacute or chronic cases the deformity is usually present without rigidity, and the pain is minimal. Fig. 469. Method of Palpation of the Spinous Processes ' FOR Tenderness. (See text.) DISEASES AND INJURIES OF THE SPINE. The deformity, or gibbus, as it is called, may be quite sharp and cause an angular prominence of the spines of only two or three vertebrae, or it may involve a number of vertebra. The curve in the latter in- stance, is a more gradual one. This is especially apt to be so in the more chronic cases. Accompanying this angular deformity there are marked changes in the contour of the head and thorax, as well as a retardation of the general body growth. 4. Abscesses. — x\lthough at autopsy a collection of pus is invariably found, it can be recognized clinically in only one-half of the cases. In cer- vical disease, the abscess is found either in the retropharyn- geal space or in the lateral re- gions of the neck. In the latter location it simulates an abscess having its origin in caseous lymph-nodes, but is usually larger and accompanied by the spinal symptoms — rigidity and pain on movement. In disease of the dorsal re- gion the abscess may appear upon the back and simulate a lipoma (Fig. 134), or an abscess having its origin in disease of the ribs. Disease close to the dorsolumbar junction causes ab- scesses which may appear (a) in the lumbar region over the kid- ney, or (b) above Poupart's hga- ment, simulating a reducible oblique inguinal hernia, or (c) over Scarpa's triangle, simulating a femoral hernia (Fig. 471). In the two latter locations the detection of fluctuation, the absence of an impulse on coughing, and the spinal symptoms soon clear up the diagnosis. Fig. 470. — Kyphosis at Dorsolumbar Junction, due TO Tuberculosis of the Last Dorsal and First Lumbar Vertebra. K, Points to apex of kyphosis, or backward angle of deformity of spine; P, points to a large psoas abscess, the anterior view of which is seen in Fig. 471. TUBERCULOUS SPONDYLITIS. 689 5. Spinal Cord Symptoms. — These are an infrequent complication, but occur especially often in the more acute cases. The motor paraly- sis is usually the most marked symptom. It varies from weakness to complete loss of power. The paralysis is at first of the flaccid type, but later spasticity with resul- tant contractures occur. The paralysis sets in gradually, but may increase rapidly, with ex- acerbations. It often improves with betterment of the local condition. In upper cervical disease the arms and legs are both para- lyzed, and there may be dys- phagia, etc. In these cases death may occur suddenly, fol- lowing spontaneous dislocation of the atlas upon the axis. The sensory paralysis is very atypical because the posterior portions of the cord are but httle involved. There may be anesthesia or hy- peresthesia, or only paresthesia. The reflexes are exaggerated at first, but later are absent. In addition to the chief diag- nostic features of tuberculous spondylitis just enumerated, viz., rigidity, pains, deformity, abscesses,' and paralyses, it is of great value to obtain a his- tory of tuberculosis in the family or of foci elsewhere in the body (lymph-nodes, joints, lungs, kid- - ney, testis, peritoneum, etc.). The general condition shows quite marked changes. The ])atients arc emaciated and anemic. There is a difference between morning and evening temperatures of from one to three degrees. Differential Diagnosis.— IFry-wec^.— Disease of the cervical spine must be differentiated from the various forms of wry-neck. The principal features of the rheumatic, congenital, and inflammatory forms, 44 Fig. 471. — Enormous Psoas Abscess over Scarpa's Triangle in Boy Suffering from Tuberculous Spondylitis of the Dorsolumbar Region. 690 DISEASES AND INJURIES OF THE SPINE. the last named from inflamed lymph-nodes, have been fully considered on page 150. Diseases close to the dorsolumbar junction must be differentiated from the following conditions: Hip Disease. — This has been considered on page 632. The re- striction of motion at the hip in Pott's disease is in only one direction, viz., hyperextension, owing to contraction of the psoas. The lumbar spine, although held somewhat rigid in hip disease, as a compensatory condition, is arched and less fixed than in Pott's disease. Other Forms 0} Backward Curvature or Kyphosis. — -Rachitic kyphosis is a gradual one extend- ing over the entire dorsal and lum- bar regions. There is no muscu- lar rigidity, and there are always other signs of rachitis (see page 590). Senile kyphosis (Fig. 114) in- volves chiefly the dorsal vertebrae, and is also gradual. There is no rigidity or pain. Other condi- tions which require differentiation are scoliosis (page 691), hysterical spine (page 692), arthritis defor- mans of the spine (page 691), ma- lignant disease (page 693), and acute osteomyehtis of the spine (page 691 ). JL Fig. 472. — Scoliosis. Showing principal curvature to right in dorsal region, and compensatory, in opposite direction, in lumbar and cervical regions. The prominence of the posterior portion of the thorax well marked on side of curvature. The difference in the contour of the chest also to be noted. SCOLIOSIS (LATERAL CURVATURE OF THE SPINE). This is an affection which appears during the years of growth, i. e., from the sixth to the sixteenth years. Often the first complaint is from the parents, who have noticed that the child carries one shoulder higher than the other. In the majority of cases the diagnosis can be readily made by inspection from behind when the patient is divested of the clothing down to the level of the hips (Fig. 472). The most frequent curve of the spine is that in which there is a convexity in the dorsal region, to the right (right dorsal scohosis). The right shoulder is higher, the scapula ACUTE OSTEOMYELITIS OF THE SPINE. 69I on the side of the convexity stands out, and is also higher than its oppo- site. The thorax below the scapula on the same side is more rounded, and there is a corresponding enlargement on the left side of the front of the thorax. There is a much wider space between the right arm and the side of the trunk than on the left side. If the spines of the vertebrae are marked with ink the curvature becomes quite clear. There are always com- pensatory curves in the opposite direction above and below the primary one (Fig. 472). The cervicodorsal and lumbar curvatures are less frequent than the dorsal. Lateral curvature may result from various causes, viz.: (i) Rachitis; (2) a sequela of infantile paralysis; (3) torticollis; (4) occupation; (5) chest diseases, especially after empyema; (6) a sequela of sciatica; (7) as a result of faulty posture. The latter is the most frequent. ARTHRITIS DEFORMANS OF THE SPINE (SPONDYLITIS DEFORMANS). This occurs as a part of the general disease of the joints previously described (page 615). As elsewhere its chief clinical features are pains and gradually increasing stiffness of the spine. Gonorrhea is a not infrequent cause. The disease occurs oftenest in elderly persons, but may be one of the manifestations of a generalized arthritis deformans at any age (Fig. 413). The patients at first complain of pains like those of rheumatism, especially referred along the cervical and branchial nerves. This stage is soon followed by gradually increasing rigidity, most marked in the cervical region. The patient is unable to flex or rotate the neck. In some cases flexion is possible, but there is inabihty to extend the neck (Fig. 414). In many cases the cervical region is the last to be affected, the lower part of the spine being first involved. The spinal rigidity is often accom- panied by the same condition in the hips. There is no angular deformity as in Pott's disease, the whole spinal column is more apt to be involved, and there is no tendency to abscess formation. Spondylitis deformans is a frequent complication of gonorrhea. The diffuse stiffness of the spine, the slight backward curve, the presence of the same conditions in the hip, knee, and other joints, as well as the absence of muscular rigidity, are the chief diagnostic points. ACUTE OSTEOMYELITIS OF THE SPINE. This rather rare affection presents no difficulties of diagnosis. The onset is a sudden one, with severe pain, high fever, tenderness on prcs- 692 DISEASES AND INJURIES OF THE SPINE. sure, and muscular rigidity. The formation of abscesses occurs early, and is indicated by the appearance of redness, induration, and heat in the vicinity of the affected vertebrae. TYPHOID SPINE. This appears during convalescence from typhoid, and is most apt to involve the lumbar portion of the spine. There is localized tenderness and pain. Disturbances of sensation, such as paresthesia and hyper- esthesia, are frequent. The diagnosis can be made from an acute form of tuberculous spondylitis, by the absence of angular deformity, and of abscess formation, as well as from the history of a preceding typhoid. HYSTERICAL SPINE. This occurs oftenest as the result of an injury, and has been pre- viously discussed under the head of spinal concussion (page 683). It is a local spinal manifestation of a general neurasthenia. By careful and repeated examinations one can readily eliminate any or all of the other forms of genuine spinal disease. There is complaint of tenderness, which is often greatly exaggerated. There is no true rigidity, although some may be feigned, and can be discovered when the attention is diverted. Pressure over the same spinous process will at one examination be said by the patient to be very painful and later not noticed. TUMORS OF THE SPINE AND SPINAL CORD. Neoplasms, whether they arise from the vertebrae, from the meninges, or from the cord itself, can, as a rule, only be recognized hy the symptoms resulting from pressure upon the spinal nerves and cord. Schlesinger has recently collected 151 cases. Of these 104 involved the vertebrae primarily, 4 grew into the spinal canal from without, 11 arose from the dura, 4 from the pia-arachnoid, 5 from the nerve-roots, and 20 were intramedullary. As a rule, all of these tumors are of more diagnostic, than therapeutic interest. The majority of those which arise from the vertebrae are of secondary carcinomatous nature. The latter are frequent after primary growths in the breasts, thyroid, and i)rostate. I'hose which are not metastatic are primary fibromata or sarcomata of the bodies. The most frequent meningeal and intramedullary growths are the gumma, TUMORS OF THE SPINE AND SPINAL CORD. 693 tubercle, glioma, and sarcoma. The gliomata give rise to a clinical picture described as syringomyelia (page 624). The first symptom to attract the attention of the patient, in all of these neoplasms, is pain. The pains afl'ect a, single spinal nerve or a pair. Often a persistent unilateral or bilateral intercostal neuralgia is one of the earliest symp- toms. At first the pains are mild, but may become sharp and lancinat- FiG. 473. — Cutaneous Nerve Supply to the An- terior Surface of the Body (Seiffer). Fig. 474. — Cutaneous Nerve Supply to the Pos- terior Surface of the Body (Seififer). ing, or remain as a constant dull ache. These pains are at first accom- panied by hyperesthesia over the area of distribution of the nerve. This neuralgic stage may persist for months to years, and the patient be treated for neurasthenia, etc., until signs of motor irritation and paralysis appear. The symptoms of motor irritation, like twitchings, spasms, and rigidity, are soon replaced by muscular weakness and finally by complete paralysis. The latter is at first apt to affect only 694 DISEASES AND INJURIES OE THE SPINE. one extremity, but the opposite one is soon involved, so that a para paresis or paraplegia develops. The sensory symptoms most frequently correspond to the Brown- Sequard type (page 666), but the anesthesia is also frequently bilateral. The reflexes below the level of the lesion are markedly increased, and this exaggeration follows the paralysis closely, the reflexes being lost when the compression is total. There is early involvement of the sphinc- ters of the bladder and rectum, as well as the development of extensive decubitus. To locate the seat of the tumor a knowledge of the areas Fig. 475. — Fistula of Coccygeal Region Leading into a Dermoid Cyst. The arrow points to the black spot which represents the opening of the fistula. of cutaneous sensation supplied by the various spinal segments is of the greatest importance (Figs. 474 and 473), as showing the upper levels of the dysesthesia. The diagnosis depends upon a knowledge of the more or less regular order and gradual appearance of the symptoms, viz.: (a) Neuralgic pains; (b) monoplegia, later paraplegia; (c) anesthesia; following motor paralysis; (d) exaggerated, and absence of reflexes. The presence or history of a primary growth elsewhere is of great value. From Pott's disease malignant disease can be differentiated by the SACROCOCCYGEAL TUMORS. 695 fact that the deformity when present is not angular, as in Pott's disease, but more rounded. In those tumors which arise from the cord itself there is no deformity, only neuralgic pains and muscular stiffness. The pains are never as severe in Pott's disease as in tumor. The symptoms of tumors of the cauda equina do not differ from those of injuries of the same (page 670). SACROCOCCYGEAL TUMORS. A number of interesting congenital conditions are found in the region of the sacrum and coccyx. They may be of three varieties: 1. Teratomata. — -These are irregular, pendulous tumors attached to the posterior surface of the sacrum or coccyx. In one class rudiments of the skeleton and of the different viscera are found. These are remnants of a parasitic fetus, which has failed to develop. In another class there is a great variety of tissues which do not, however, represent any single organ. 2. Cystic Tumors Behind the Rectum. — These are found between the rectum and sacrum. The majority have their origin in persistent remnants of the post-anal gut and neurenteric canal. The unilocular variety form large cysts, and may project into the rectum. The multi- locular form is made up of a number of cysts, each containing a rope- like substance resembling mucus. Dermoids also occur within and be- hind the rectum, and may attain a large size. 3. Sequestration Dermoids. — These occur over the sacrum and coccyx, and allied to them are the sinuses and dimples which occur here (Fig. 475). The sinuses open near the tip of the coccyx. CHAPTER VII . POSTOPERATIVE COMPLICATIONS. These have assumed such importance at the present time, when the scope of operative interference has been so greatly extended, that the abihty to recognize them at an early period renders it advisable to add a chapter on the subject. They may be divided in one of two ways, viz. : A. According to the individual operations ox regionally, i. e., the part of the body operated upon. B. According to the most prominent symptom or the organ in- volved in the complication. The latter classification seems the most satisfactory from a diag- nostic point of view and will be followed here. According to this mode of division the most important postoperative complications are: 1. Hemorrhage. 2. Shock and collapse. 3. Infection, not including peritonitis. 4. Pulmonary complications. 5. Cardiac complications. 6. Hepatic complications. 7. Gastro-intestinal complications, including postoperative ileus and peritonitis. 8. Postoperative ileus. 9. Postoperative peritonitis. 10. Renal comphcations. 11. Circulatory comphcations (thrombosis, etc.). 12. Miscellaneous postoperative complications. HEMORRHAGE. Hemorrhage following an operation may occur from the wound itself in one of three ways: (a) As the result of imperfect hcmostasis, either from hgating bleed- ing vessels too loosely or not having secured a sufficient number of bleeding vessels, the temporary closure by clots being disturbed through movements of the patient. 696 HEMORRHAGE. 697 (b) As the ]-csult of constitutional causes. In this group belong those unavoidable hemorrhages which occur as the result of hemophiha and long-continued jaundice. (c) As the result of infection of the wound. The thrombi, which obliterate the cut ends of the vessels, become disintegrated as the expres- sion of a purulent softening due to microorganisms. This was formerlv called secondary hemorrhage and was far more f recjuent than at present, when septic infection is rare. Hemorrhage may take place after operations either (a) in such a way that it can be recognized at once by the reddish staining of the dressings, accompanied by increasing symptoms of anemia, i. e., external hemorrhage, or {h) there may be no escape of blood from the w^ound or the latter may not be accessible to observation. Such postoperative bleeding is apt to follow intraabdominal operations or those upon the stomach or rectum. These last-named hemorrhages may be properly termed concealed or internal, since they can only be diagnosed by recognizing the symptoms characteristic of internal hemorrhage in general, viz., those of rapidly increasing anemia and the other symptoms, such as recurrent attacks of syncope, thirst, restlessness, and rapid, empty pulse. The diagnosis of the actual existence of the first chnical variety, viz., external hemorrhage, presents no difficulty. The blood is seen escaping either in large quantity, or there is constant oozing which fre- quently resists all of the ordinary methods of treatment. At times a gradually increasing hematoma may be the expression of this form of postoperative hemorrhage. In cases where the hemorrhage is due to constitutional causes, like hemophilia, inquiry into the previous history of the patient himself or of the family will often result in a history of frequently recurring obstinate hemorrhages from the slightest of causes. Hemorrhage due to persistent jaundice, almost invariably follows gallstone operations, and may often be recognized as such by an exami- nation of the coagulation time of the blood, this being greatly decreased. Hemorrhage as the result of sepsis appears much later than either of the two preceding, and is accompanied by such marked local signs that its recognition is not difficult. The hemorrhage spoken of as concealed or internal is much more difficult to recognize than any of the above. It may follow any o[)eration in a serous cavity, such as the brain, pleura, or peritoneum. In the brain the symptoms are those characteristic of cerebral compression (see page 36). In the peritoneal cavity the symptoms resemble those 698 POSTOPERATIVE COMPLICATIONS. following rupture of an extrauterine pregnancy, viz., gradually increasing pallor, soft, thready pulse, restlessness, and great thirst. Locally there are signs of irritation, from the presence of free blood in the peritoneal cavity. These symptoms of peritoneal irritation are rigidity of the ab- dominal wall gradually becoming quite diffuse, accompanied by tender- ness on pressure, and a moderate amount of tympanites (from paresis of the intestinal muscles). These symptoms are the same as those of a beginning peritonitis, and the question may be asked. How can the diag- nosis of internal hemorrhage be made from those of a beginning septic peritonitis? The answer is, that if the hemorrhage is not sufficiently marked to produce signs of general anemia, a differentiation in the early hours is impossible. Later on, i. e., after six to twelve hours, the con- tinuation and increase in gravity of the peritoneal symptoms, unaccom- panied by those of general anemia, indicate septic infection. In some cases both may be combined and the symptoms of hemorrhage in the early hours be followed by those of peritonitis later. In general it may be said that the signs of internal hemorrhage appear soon after an operation, i. e., in the first six hours, while those of infection occur at a later period. A gradual fall in blood-pressure may also be of aid in distinguish- ing hemorrhage from postoperative peritonitis. The diiferentiation of shock from both of these conditions is considered under postoperative peritonitis and shock respectively. Hemorrhage may occur after operations like a gastro- enterostomy or those on the rectum, hke hemorrhoids, etc. The bleeding may take place into the lumen of the stomach or bowel in the first-named class of operations or into the rectum in the latter. The early recognition of such cases is often impossible except from the actual inspection of blood, either vomited or passed with a bowel movement. The reason for this is that such a passage of blood may not occur until the patient is almost exsanguinated. The only manner in which to diagnose such a concealed hemorrhage before either a bloody vomit or a tarry stool occurs, is by watching for the ordinary signs of internal hemorrhage. These are (a) gradual or rapidly increasing pallor of the skin and visible mucous membranes (lips, gums, tongue, and conjunctivas); (b) restlessness, often accompanied by dehrium or stupor; (c) great thirst; (d) the pulse becomes soft and very weak; (e) rapid fall of blood-pressure. The rate is not necessarily increased, since Nature's effort to check the hemorrhage is by the gradual onset of syncope. When hematemesis or evacuations of large quantities of SHOCK AND COLLAPSE. 699 fresh or old tarry blood take place, accompanied by these signs of anemia, the diagnosis of concealed hemorrhac;e is not difficult. SHOCK AND COLLAPSE. The diagnosis of shock as a comphcation of injuries has already been referred to (see page 525). A similar condition may follow an operation, at times resulting in the death of the patients. The essential factor, as Crile has shown, is the exhaustion of the vasomotor centers, resulting in the blood collecting in the splanchnic area and a resultant fall in general blood-pressure. The heart is affected secondarily through the fall of blood-pressure, causing stagnation in the great venous trunks, and thus interfering with its action. Postoperative shock is most apt to follow prolonged operations, and is especially frec|uent after those upon the viscera in the upper half of the abdomen. Collapse or syncope may follow operation, and is also due to a fall in blood-pressure, but from a different cause. It may be a sudden paralysis of the vasomotor centers, resulting from some violent afferent nerve stimulus, or it may be due to a sudden loss of blood. The clinical conditions described under hemorrhage should not be called collapse, since the vasomotor centers are intact. When, however, col- lapse following a severe hemorrhage has persisted for a considerable time, it begins to change into the condition of true shock, as the vaso- motor centers become exhausted from their efforts to maintain the blood-pressure at the same level. The chief symptoms of postoperative shock are the same as those following injury. These are (a) marked pallor and coldness of the skin and visible mucous membranes, accompanied by a slight tinge of cyanosis; (b) a small, irregular, and rapid pulse; (c) a stuporous or apathetic appearance of the patient. The symptoms vary according to the cause. If they are the result of a sudden vasomotor nerve paralysis, there is almost complete arrest of the heart's action, marked pallor, dilated pupils, cold sweat, cold often slightly cyanotic extremities, feeble or absent respiration, and almost complete loss of consciousness. If the collapse is due to severe hemor- rhage, these symptoms differ only in having appeared after a period during wJu'ch the signs of sucli hemorrhage, viz., of anemia, predomi- nated. In some cases it is almost impossible to determine whether the condition of the patient is due to hemorrhage or shock. This has already been referred to in the diagnosis of concealed or internal hem- orrhage. yoo POSTOPERATIVE COMPLICATIONS. In general, shock is more apt to follow prolonged operations or those upon the brain, genitalia, abdominal viscera, etc. The restlessness, pallor, and weakness of the pulse are not nearly as marked in shock as in hemorrhage. In some cases it is very difficult to distinguish myocardial symptoms, such as a rapid, weak pulse, from those of shock. INFECTION AS A COMPLICATION OF OPERATION. Infection, like hemorrhage, may be recognized either through visible local signs combined with those of a more constitutional nature, or the latter may predominate to such an extent that the local signs become insignificant. The most important of the general signs which indicate infection is usually a rise of temperature. In the majority of patients there is a slight rise of temperature for the first twenty-four to thirtv-six hours after an operation. It is well to remember that in children this post- operative aseptic fever is relatively higher than in adults, and may be accompanied, especially in nervous children, by an increased pulse-rate, which would be alarming under other circumstances. The temperature under these conditions varies greatly. It is usuallv from 99° to ioi° F., rarely higher. The rise takes place within twelve hours after the operation, dropping to normal a few hours later. It is supposed to be due to the absorption of fibrin ferment from the wound, and is called, for lack of a more exact name, "ferment or aseptic fever." If, however, the rise of temperature should recur upon the evening of the second day after the operation, suspicion should be aroused that infection has taken place. This secondary rise or continuation of the immediate postoperative fever will remain for a variable period, accord- ing to the nature of the infective lesion, and will usually be accompa- nied by local signs indicative of the virulence of the infection. The various septic complications of an operative wound differ in no par- ticular from those following an injury. It will, therefore, not be necessary to repeat here what was said on pages 529 to 55-]. about sapremia, pyemia, and the other infective wound diseases. At times, however, infection may occur in a wound with very little, if any, fever, owing to the low grade of virulence of the organisms. After operations Avithin the cranial, pleural, or peritoneal cavities infection of the corresponding serous membrane may occur. The symptoms and recognition of these complications rcfjuire no special mention, since they dift'cr but little, except in the history, from those PULMONARY COMPLICATIONS FOLLOWING OPERATIONS. 70I originating without such operative wound. The diagnosis of post- operative septic peritonitis will be considered in connection with that of postoperative ileus. PULMONARY COMPLICATIONS FOLLOWING OPERATIONS. The increased frequency of these, has directed the attention of sur- geons not only to their early recognition, but to the study of their causes and prevention. It is not within the province of this book to discuss the latter. The frequenc}^ with which the various forms of postopera- tive pulmonary complications occur and their relative influence on results are well shown in a recent pubhcation of Bibergeil.^ He found 283 pulmonary complications, i. e., 7.2 per cent., in 3909 abdominal opera- tions from Korte's cUnic. Of these 815 were operations above the umbiKcus. 2625 were operations below the umbilicus. 469 were operations both above and below the umbilicus. These complications were: Mortality. 1. Pneumonia (lobular, lobar, hypostatic) ^35 i-i per cent. 2. Pulmonary embolism 12 0.3 " " 3. Pulmonary infarcts 9 ii.o " " 4. Bronchitis 82 5. Pulmonary abscess '. * 12 6. Dry pleurisy 3 7. Pleurisy with effusion 16 8. Empyema 13 9. In addition to these mentioned, among quite rare pulmonary complications are gangrene and acute edema. For every hundred abdominal operations there were 3.5 per cent, pneumonias, either lobar, lobular, or hypostatic. This corresponds to the relative frequency in other large German chnics. The frequency of pulmonary complications is, of course, greatest in advanced life, or where there has been a preexisting bronchitis, etc. That postoperative pulmonary complications are not always the result of a general anesthetic, like ether, is demonstrated by the frequency with which they occur after local anesthesia. These complications are, as stated above, most frequent after lap- arotomies, but they may occur as a result of almost any operation, such as operations in the mouth, herniotomies, ligation of varicose veins, etc. They are especially frecjucnt after incarcerated or strangu- lated herniie. ' ".Arcliiv fiir klinischc Chirurgie," vol. Ixxviii. 702 POSTOPERATIVE COMPLICATIONS. The most common modes of origin are (a) by aspiration of mucus or vomitus; (b) by the detachment, from the field of operation, of thrombi which are carried to the lungs; (c) migration of organisms through the diaphragm. The recognition of these various forms of pulmonary comph cations usually presents no difficulties, since t]ieir physical and general signs differ but Utile from those observed in non-operated cases. The lobular and hypostatic forms of pneumonia occur far more frequently than does the lobar or croupous variety. The latter affects the right lower lobe oftener than any other. Lobular and lobar pneumonia, pulmonary edema, pleuritis, and bronchitis belong to the complications which occur within the first week after an operation. Pulmonary infarcts, embolism, abscess, gangrene, empyema, and hypostatic pneumonia usually occur at a later period. In a few cases pulmonary edema immediately followed the administration of the anesthetic. One of the most distressing of these comphcations is pulmonary embolism. This may occur at such a late period, e. g., when the patient is getting up, that all thought of any complication has been dismissed. A thrombus becomes detached, apparently without cause, from a vein in the vicim'ty of the field of operation, and is swept through the right heart into the pulmonary artery. It lodges in one of the primary bifurcations of the latter vessel (Fig. 476), and gives rise to most serious symptoms and often causes death. Some of the emboh may not occlude the vessel, but float to the periphery of the lung and cause subpleural patches of embolic lobular pneumonia. In 40 out of 66 cases of pulmonar}^ embolism collected by Lotheissen (quoted by Gebele^) the origin of the thrombus was in the veins of the leg; the next most frequent seat was the pelvic veins. The recognition of the more serious form of pulmonary embolism is important. The symptoms usually appear quite suddenly at a time when least expected. There is great dyspnea, accompanied by cyanosis and shallow rapid respirations. The pulse becomes rapid and almost imperceptible, and death may ensue within a few minutes. In cases in which one recovers from this condition, the above symptoms grad- ually diminish in severity. The physical signs are practically nil. CARDIAC COMPLICATIONS. A patient with a normal heart very rarely develops postoperative cardiac comphcations. The effect of the anesthetic is a transient one^ ' Gebele: "Beitrage zur klin. Chir.," vol. xlv. niBs^mmBtmmtt Fig. 476. — Section of Lung Showing Ramifications of Pulmonary Artery and Lodgment of an Embolus in One of the Points of Bifurcation of the Vessel. This is condition found at autopsy in cases of pulmonary embolism. (See text.) HEPATIC COMPLICATIONS. 703 as a rule, leaving no trace after the patient has recovered consciousness. Even under pathologic conditions, it has been found that the anes- thetics most frequently given, ether and chloroform, have no ill effects in the majority of cases of valvular lesions. It is only in cases of myo- carditis that postoperative complications are hable to follow. In these death may occur as a result of the myocarditis, in from one to several days after the operation, the severity of which has been increased by the operation. Under the latter conditions, in elderly patients one not infrequently notices marked irregularity in the rhythm and volume of the pulse following an operation. In general the signs of such a myocarditis are an irregular, weak, and rapid pulse with feeble heart tones and evidences of cardiac dilatation. HEPATIC COMPLICATIONS. 1. Icterus. — This may occur from a number of different causes, for example: (a) It may be a symptom of an acute gastro-enteritis, occurring as a result of the toxic effects of the anesthetic upon the digestive tract. (&) It has been described as a direct result of the toxic action of chloroform upon the blood. This is very rare, if it ever occurs. (c) It may be a symptom of one of the postoperative complications to be described, as cholemia or acid intoxication. (d) Postoperative obstruction of the common duct by a gallstone, which has either been overlooked during an operation for gallstones, or has passed down into the common bile-duct from the seat of forma- tion of the calculus in the intrahepatic bile-ducts. The diagnosis of the cause of the jaundice in a given case can only be mad€ by a careful study of the accompanying symptoms. 2. Acid Intoxication. — This condition is placed under the head of hepatic comphcations because in a number of cases, in which the Hver has been examined microscopically, acute fatty degeneration in some cases ^ and necrotic changes in the parenchyma in others ^ have been found. This complication has been given various names, such as cholemia, acidosis, acetonemia, and acid intoxication. The last-named term seems the most appropriate for the present, although the condition is one of a toxemia due to hepatic insufticicncy. It may be the result ^ Bevan and Favill: "Jour. Amer. Med. Assoc," Sept., 1905. 2 Eisendrath: "Jour. Amer. Med. Assoc," Nov., 1901. 704 POSTOPERATIVE COMPLICATIONS. of a number of toxic agents, viz., anesthetics (especially chloroform)^ poisons, infective microorganisms, and pregnancy. These alTect the secreting cells of the liver, and prevent their normal function. Acetone and diacetic and oxybutyric acids are found in both the blood and urine. They are, however, to be regarded as by-products, and not as the essen- tial causes. They are of various degrees. In the milder form the recovery is rapid, showing as symptoms only restlessness, mild delirium, and drowsiness after the anesthesia. Be van and Favill have collected 30 cases, of which 28, including their own, were fatal. Twenty-three of the 30 follov^ed chloroform anesthesia. In the graver cases the symptoms are delirium, vomiting, restlessness, convulsions, coma, Cheyne-Stokes respiration, cyanosis, and icterus in a variable degree. The most characteristic symptoms, according to Brewer,^ are a sweetish odor of the breath, delirium, and rapidly fatal coma. According to Kussmaul, to these symptoms are to be added "air hunger," /. e., deep breathing accompanied by a bright red color of the mucous membranes. In the case described by the writer in 1901, the chief symptoms were delirium, coma, intense jaundice, and very high temperatures, to 108° F. These symptoms of acid intoxication have appeared from ten to one hundred and fifty hours after operation. GASTRIC COMPLICATIONS. The most frequent gastric comphcations are : 1. Vom^iting. 2. Hematemesis. 3. Acute dilatation of stomach. I. Vomiting after operation may occur at various periods, and the diagnosis of its cause rests upon three factors: (a) Length of time which has elapsed since the operation. (b) Character of vomitus. (c) Accompanying symptoms. (a) Length of Time after Oferation. — If the vomiting is due to the anesthetic, it usually occurs before the patient has become fully conscious, i. €., in the first twelve to twenty-four hours after operation. Ether and chloroform differ somewhat in this respect. If due to ether, it occurs usually before the patient regains consciousness and is l)rief in duration. It begins early and ends early. With chloroform, the nausea and vom- iting may begin immediately after operation, but more commonly they ^ "Annals of Surgery," vol. xxxvi. GASTRIC COMPLICATIONS. 705 begin late, being delayed as long as twenty-four hours. Postoperative chloroform vomiting is quite persistent, often lasting three to four days. If vomiting after either anesthetic persists longer than twenty-four to forty-eight hours after operation, other postoperative comphcations must be thought of, and search made for symptoms which will either confirm the suspicion of their presence, so that a diagnosis may be made, or exclude their presence. One of the most frequent causes of prolonged postoperative vomiting, is defective excretion of urea, and not infre- quently uremic complications are overlooked until too late to be remedied. Persistent nausea and vomiting as symptoms of nephritic complica- tions will be referred to again, under renal complications. Other causes of vomiting appearing later than the ordinary post-anesthetic vomiting may be due to acute dilatation of the stomach, postoperative ileus, and peritonitis. The diagnosis can only be made in such cases from the character of the vomitus and the symptoms characteristic of these con- ditions. Let it not be forgotten that occasionally chloroform vomiting will persist for a number of days, accompanied by violent headache and great depression. The majority of these cases are due to renal compli- cations. Another cause of late postoperative vomiting is that of acid intoxication (see page 704). Obstinate postoperative vomiting has frequently been observed fol- lowing abdominal operations in neurotic individuals. (b) Character of Vomitus. — The vomitus which occurs after ether or chloroform anesthesia consists of mucus, or mucus mixed with bile. If it persists for some hours after anesthesia, it may consist of bile alone. In operations about the mouth, nose, or throat the vomiting of large amounts of blood, /. e., hematemesis, may be a complication of an ab- dominal operation and is referred to later. In acute dilatation of the stomach, which will also be described, the vomitus is a brownish sour hquid, which attracts attention on account of the large c^uantities brought up with each effort. The diagnosis of these conditions can be made from the brownish character of the vomitus, from the accompany- ing symptoms of collapse and the distention of the upper abdomen. The vomiting occurring as a result of postoperative peritonitis or ileus will be described under three heads. (c) Accompanying Symptoms. — The \omiting due to ether or chloroform is seldom accompanied by other symjjtoms than those of nausea or vertigo. If the vomiting due to one of these anesthetics persists for a number of days, it is accompanied by great mental depres- sion and anxiety, hollow sunken eyes, retracted abdomen, diminished 45 7o6 POSTOPERATIVE COMPLICATIONS. excretion of urine, dry sidn, etc. If vomiting is due to other causes, such as postoperative nephritis, ileus, peritonitis, acid intoxication, or acute gastric dilatation, the symptoms are those described under the respective heads in this chapter. 2. Postoperative Hematemesis. — Reference has already been made under the head of "hemorrhage" to the vomiting of blood, occur- ring as the result of an improperly performed gastro-enterostomy. One of the first to call attention to this condition was von Eiselsberg, in 1899. He reported a number of cases in which it followed ligation of the omentum. Since this time, a number of others have directed attention to this postoperative complication. It has been found to follow a variety of abdominal operations, even on organs Hke the appen- dix. The etiology of the condition is still a matter of dispute. The vomiting of blood begins within the first twenty-four hours after the operation, there usually being an interval between the vomiting which is due to the anesthetic and that of the hematemesis. Usually an ounce of intensely acid blood is vomited at frequent intervals. The general condition is similar to that of an intense toxemia, with rapid, small pulse, and cold, moist skin. This condition is followed by a rapidly progressing collapse. The diagnosis presents no difficulty, especially if the black blood vomited at frequent intervals is accompanied by the symptoms of toxemia mentioned above. The only condition with which it could possibly be confused, is acute dilatation of the stomach. In this, the vomitus is thin and brownish and the symptoms of collapse appear much more rapidly. The enormous swelling of the upper abdomen, with displacement of the lower viscera and interference with respira- tion, are also important diagnostic signs of acute dilatation. 3. Acute Gastric Dilatation. — ^This condition was formerly con- sidered to be a very rare complication, but more recent observation has shown it to occur comparatively frequently. This later view is the result of closer observation and earlier diagnosis. The generally accepted theory of etiology is that it is the result of a paralysis of the muscles of the stomach wall, either of central or local origin, and may follow any abdominal operation, especially those upon the gallbladder and kidney. The earhest and most common symptom is nausea and vomiting. This may begin soon after recovery from the anesthesia, increasing in severity in proportion to the degree of dilatation. In other cases it may not begin until the second or third day following the opera- tion. POSTOPERATIVE ILEUS. 707 The vomiting can be distinguished from the ordinary postoperative vomiting by the gradual increase in the quantity of fluid. Enormous quantities of thin, broAvnish, sour fluid are vomited. The emesis is accompanied by symptoms of collapse. The upper half of the abdomen is at the same time much distended and dull on percussion, thus differ- entiating it from postoperative ileus, where it is tympanitic. The temperature is either normal or subnormal, the pulse increased in fre- quency, and the urine either greatly diminished or there is complete suppression. Through the stomach-tube, an excessive quantity of brovmish fluid escapes. The change in contour of the upper half of the abdomen, and the decreased area of dullness after every expulsion of vomitus, show that this fluid is not free in the peritoneal cavity. Many of the milder cases recover spontaneously, although the majority end fatally unless speedy relief is given. POSTOPERATIVE ILEUS. This subject has attracted considerable attention. Various divis- ions have been suggested. The one hitherto accepted by the majority of surgeons has been that of Mikulicz into: (a) Mechanical. (b) Dynamic. Finney^ has recently suggested what seems to be a better classifi- cation; his division is as follows: (a) ]Mechanical. (b) Septic. (c) Dynamic. While the distinction is very often impossible, the diagnostic fea- tures are generally as follows: Mechanical ileus is characterized by later onset, visible peristalsis, and severe colicky abdominal pains. The abdominal distention is asymmetrical, and at first there is no change in the pulse or tempera- ture. Later the condition is characterized by persistent vomiting and constipation. Septic ileus is often masked by the general signs of septicemia, thus differing in its clinical aspect from that of mechanical ileus. A dynamic ileus develops as the result of a paralysis of the intestinal muscles, with few of the signs of obstruction and none of the signs of septicemia. The diihculty of differentiating an acute ileus from an acute peritonitis is apparent, and the later the case is seen, the more ^ "Annals of Surgery," June, 1906. 705 POSTOPERATIVE COMPLICATIONS. difficult does this differentiation become, for advanced cases of obstruc- tion are almost always complicated by peritonitis. In both conditions the leukocytes are increased, and in both the opsonic content of the blood is very high. The method of estimating this opsonic content of blood has recently been studied by Simon and Lemar.^ This will be de- scribed on page 716. In favor of the diagnosis of obstruction are a rapid, feeble pulse; ashy, pinched countenance; rapid distention of the abdomen, which is not board-like; increased peristalsis; earlv and severe vomiting, soon becoming fecal; severe, cramp-Mke pain referred to the umbihcal region, and absence of fever. In some cases of postoperative obstruction no symptoms appear until weeks or months after the operation. The symptoms are usuallv due to bands or adhesions. The diagnosis in these cases presents no difficulty. The symptoms of obstruction appear in a patient Avho has previously been subjected to an abdominal operation. There are other cases in which adhesions following an operation result in incomplete obstruction. In this class, especially frequent after appendiceal operations, the patients present a variety of symp- toms. The patient may complain simply of colicky pains, accompanied by more or less abdominal distention and constipation. In other cases there is the history of cohcky pains, accompanied by nausea and vomiting, recurring at irregular intervals. A form of postopera- tive ileus of the mechanical type, to be especially mentioned, is stran- gulation of a loop of intestine in a postoperative hernial opening. This may occur months or years subsequent to an operation. POSTOPERATIVE PERITONITIS. The occurrence of peritonitis is comparatively infrequent, as a postoperative complication at the present time. The symptoms and diagnosis do not differ in any respect from those occurring in peri- tonitis complicating disease or injury of any of the abdominal viscera, that is, not following operation. The chief diagnostic points are: (a) Cohcky pains, gradually increas- ing in severity; (b) uniform muscular rigidity, and tenderness on press- ure over the abdomen; ic) rapidly increasing distention; (d) gradu- ally rising pulse-rate, reaching 140 to 160, or even higher at the end of twenty-four hours; (e) absolute constipation, regardless of cathar- tics or enemas; (/) sunken eyes; anxious expression, subnormal tem- perature, general cyanosis, cold and clammy extremities, dry, coated ^ "Johns Hopkins Hosj). Bull.," Jan., 1906, RENAL COMPLICATIONS. 709 tongue, diminished secretion of urine, vomiting and hiccough, often persistent. The symptoms which should attract the most attention are the rapidly increasing pulse-rate, the condition of the abdomen, and the complete obstipation, neither feces nor flatus being passed. RENAL COMPLICATIONS. Both ether and chloroform have an irritant effect upon the normal Iddneys. A large number of observers have found that in about 25 per cent, of all cases the administration of either of these anesthetics is followed by the appearance of albumin and of hyaline and granular casts in the urine. This condiiton of renal irritation lasts only from one to four days, as a rule, and does not give rise to any .postoperative symptoms. Cases, however, have been reported by Frankel and others where prolonged (two to three hours) administration of chloroform has been followed in eight to ten days by death. In such cases the chloroform caused marked fatty degeneration of the heart muscle, as well as of the hepatic and renal parenchyma. It has also been found ^ that during the administration of ether to animals, the excretion of nitrogenous substances is practically abolished. The question which is of direct interest in respect to postoperative renal complications is. Do ether and chloroform have any ill effects upon the diseased kidney? There is some difference of opinion in regard to this question. There are some surgeons who believe that it is perfectly safe to give ether to nephritic patients. The majority, however, believe that the administration of chloroform, as a rule, is not followed by renal complications in those previously suffering from such disease. Ether may, on the other hand, be given to a large percentage of patients suffering from nephritis of the more chronic type and not be followed by any mild or graver signs of irritation. In a certain percentage of cases there is indisputable chnical evi- dence that various forms of renal complications ma}' occur after opera- tion. This often takes place when least expected. The various clinical forms of such complications are: I. Mild uremic symptoms, such as ia) nausea and vomiting (pro- longed many days after this common postoperatix'e symptom should have ceased); (b) headache; (c) diminished (|uantily of urine, con- taining variable amounts of albumin and casts, and decrease in urea percentage. ' "British Medical Journal," Sept. 9, 1905. 7IO POSTOPERATIVE COMPLICATIONS. 2. Grave uremic symptoms — such as convulsions, restlessness, delirium, and coma. The secretion of urine may be practically abolished or it may contain the various constituents so characteristic of uremia under non-operative conditions. These may be blood, hyaline, gran- ular, and epithelial casts, renal epithelium, large quantities of albumin, and a very small amount of urea. Postoperative renal complications usually appear within twenty- four to forty-eight hours after the anesthesia. They may occur in the following classes of patients: 1. As an acute exacerbation of a latent nephritis, which had not been recognized before operation. 2. As an acute nephritis developing in a patient who had been previously known to have a chronic nephritis, either latent or active. 3. As a reflex anuria of one kidney, following operations upon the opposite, especially nephrectomy or nephrotomy. The diagnosis in all of these classes of cases can only be made: (a) by excluding other conditions which might give rise to postopera- tive nausea, vomiting, dehrium, etc.; (b) by the previous history of the case as to urinary findings; (c) by the examination of the urine both quantitatively and quahtatively. CIRCULATORY COMPLICATIONS. Thrombosis and Embolism. — Postoperative comphcations, at times of the gravest character, may be the result of a thrombosis of an adjacent vein, which has occurred either prior to such operation or has developed subsequently to it. In the former condition we speak of a preoperative and in the latter of a postoperative thrombosis. If the phlebitis is of a non -suppurative type, the condition may give rise to local signs, such as pain and sweUing, or it may cause any of the forms of embohc pulmonary complications spoken of on page 702, viz., infarcts, pneumonia, emboHsm, and pleuritis. If the phlebitis is of the septic or suppurative type the clinical picture is more hke that of a septicopyemia with the formation of metastatic foci of septic infarction or embolism. The non-suppurative type of postoperative thrombosis is compara- tively frequent. Cordier^ in a recent paper states that it occurs in about 2 per cent, of all abdominal operations. It is most common after appendectomy, herniotomy, salpingectomy, oophorectomy, and hyster- ectomy. It occurs even when the primary condition has been an asep- ' " Jour. Amer. Med. Assoc," 1905, p. 1792. MISCELLANEOUS POSTOPERATIVE COMPLICATIONS. 71I tic one. Gangrene of the affected limb has never occurred. In the majority of cases either the right or left femoral or saphenous veins are affected or the veins of both sides. In a number of cases the mesenteric or pelvic veins or those of the abdominal wall are affected. Clinically these cases of phlebitis appear in one of two forms: 1. A variable time after operation, usually from the seventh to the fourteenth day, the patient may suddenly show the signs of pulmonary embohsm described on page 702, viz., dyspnea, cyanosis, rapid pulse, etc. These are the cases in which either a diagnosis of phlebitis was not made, on account of the depth of the vein involved, or the clinical picture of a phlebitis was not recognized. 2. The phlebitis with resultant thrombosis appears about the tenth to fourteenth day. It causes pain referred to the location of the sapheni or other veins involved. Accompanying the pain there is tenderness over the course of the vein, and the latter can be felt (if the saphenous is involved) as a firm, tender cord. If the femorals are involved, there is usually quite marked swelling of the entire limb, the edema being of a firm character, and the skin glossy and pale (the phlegmasia alba dolens of former days). At times all of the superficial veins are quite prominent and thrombosed. . The diagnosis in these cases of postoperative thrombosis is usually not difficult, if veins like the sapheni or femorals are involved. In the other veins a diagnosis before the occurrence of embolic symptoms is impossible. MISCELLANEOUS POSTOPERATIVE COMPLICATIONS. Postoperative Eruptions. — (a) Surgical Scarlatina. — This sub- ject has been thoroughly reviewed by Dr. Alice Hamilton.^ It may occur 'after almost any operation, in both adults and children. It does not differ clinically from ordinary scarlatina except in the follow- ing particulars: 1. It is especially apt to attack adults. 2. The period of incubation is shorter than that of ordinary scar- latina. 3. The eruption begins at the wound or in some other unusual place. 4. The throat symptoms are either mild or absent. 5. Desquamation occurs at an earher period. In the majority of cases reported in the literature as surgical scar- ' "American Journal of Med. Sciences," 1904. 712 POSTOPERATIVE COMPLICATIONS. latina, the eruption was either due to sepsis or to erysipelas. The latter is especially apt to be puzzling to differentiate, if it begins in the throat as an angina. (b) Septic Rashes. — This greatly resembles a surgical scarlatina, but can be differentiated from it by the accompanying symptoms of septicemia. The eruption is usually a diffuse erythema, is accompanied b)^ a marked rise in temperature, rapid pulse, restlessness, etc. It usually lasts only a few days. In children it appears even in mild cases of sepsis, and frequently the eruption is the only symptom present. There are usually no changes in the wound even in the graver cases. In these cases the symptoms of septicemia (page 537) accompany the eruption. The following are some of the points which may help in distin- guishing a septic from a scarlet fever rash: 1. The premonitory febrile symptoms are usually absent, the rash being the first thing noticed in most cases. 2. The distribution of the rash is irregular; it appears often simul- taneously all over the body, and not, as in scarlet fever, on the neck and face first. 3. There are no throat symptoms, except in those cases where the wound is in the throat. 4. The pyrexia is high and of the septic type, with often marked intermissions. (c) Drug Eruptions and Poisoning. — These may either be local, as the result of the action on the skin of the field of operation, or there may be more generalized eruption. They are frequent after the use of bichlorid of mercury, carbolic or sahcyhc acids, or any preparation containing iodin. The locahzed eruption is either a fine pustular one, or there are all the signs of an acute dermatitis. The more generalized eruptions are usually of the erythematous type, often accompanied by intense pruritus. The occurrence of postoperative symptoms of iodoform, carbolic acid, or of bichlorid poisoning are so rare at the present time that they require no special mention, being fully described in the text-books on therapeutics and materia medica. DIABETIC COMPLICATIONS. These arc of the utmost importance, and may be of various forms. I. A latent diabetes mav be aroused into activit^^ POSTOPERATIVE PAROTITIS — STATUS THYMICUS. 713 2. A previously existing diabetes may be greatly intensified and cause most serious complications. Glycosuria has been found to occur in normal individuals after operations. The sugar is, however, transi- tory and is so slight in amount as to have no clinical significance. The usual forms in which postoperative diabetic complications appear, are (a) as a gangrene of the edges of the wound or of a limb with early evidences of marked sepsis; (b) as a coma accompanied by pulmonary edema and resulting fatally within a few days after the operation; (c) as a marked glycosuria, which gradually subsides without giving rise to any general symptoms. The development of these diabetic complications must always be borne in mfind, not only in those whose urine was known to contain a trace or a larger quantity of sugar before the operation, but in every patient above middle age. A preoperative urinary examination must always include the test of sugar. The diagnosis of a diabetic coma must be made by excluding other causes for coma or gangrene and finding sugar in the urine. POSTOPERATIVE PAROTITIS. This occurs most frequently after abdominal operations, and is often described as a cceliac parotitis. It may also appear as a compli- cation of inflammatory affections of the abdominal viscera. The parotid gland of one or both sides is almost invariably involved. The inflammation may be (a) of a simple type, like that occurring in the epidemic form of parotitis (mumps); (b) abscess formation may take place; (c) gangrene of the parenchyma may occur. The diag- nosis is not difficult. The appearance after an abdominal operation of a swelling, just in front of and below the ear, accom.panied by tender- ness and fever, is quite characteristic. If suppuration or gangrene occur, the local signs are correspondingly more marked. STATUS THYMICUS. This peculiar complication- of anesthesia has been recognized for some time. After the administration of chloroform, death has suddenly occurred, accompanied by symptoms of cardiac and respiratory paralysis. In the autopsies on these cases, usually children, a general hyperplasia of the lymphatic structures has been found. The thymus gland is markedly enlarged and from this finding the condition first received its name. 714 POSTOPERATIVE COMPLICATIONS. ACUTE THYROIDISM. This is a complication occurring after thyroidectomy. The symp- toms are a great rise in temperature (103° to 108° F.), high pulse-rate, face flushed, restlessness, and at times delirium and coma. The condition may be only a transitory one, or it may result fatally. POSTOPERATIVE HYSTERIA. This requires no special description. The diagnosis of the various forms, in which this protean affection may appear, does not differ in any manner from the recognition of hysteria occurring under other circumstances than as a postoperative condition. CHAPTER VIII. METHODS OF EXAMINATION. Examination of the Blood in Surgical Cases. The methods of chnical examination of the blood which are of surgical interest are: 1 . Counting the red and white corpuscles. 2. Estimation of the percentage of hemoglobin. 3. Examination for the plasmodium malariae. 4. The differential leukocyte-count. 5. The determination of the opsonic index. The technic of the first three of these is so fully discussed in the special books upon the blood and diagnostic methods that it may be omitted here. DIFFERENTIAL LEUKOCYTE-COUNT. Attention has been recently called by Gibson ^ to the value of the differential leukocyte-count in surgical cases, especially those due to infection. Normally the percentage of each variety of leukocyte, as given by Cabot, Mn the blood of healthy adults is: J Small lymphocytes 20 to 30 per cent. \ Large lymphocytes , . . 4 to 8 " (b) Polynuclear neutrophiles 62 to 70 " (c) Eosinophiles 0.5 to 4 " (J) Mast-cells 0.025 ^° °-9 " Sahli estimates the number of polynuclear neutrophiles at 70 to 72 per cent. Sondern's average for polynuclear neutrophiles in the normal blood is 68 per cent. Gibson has adopted 75 per cent, as a working average. The method of estimating the different kinds of leukocytes is readily accomplished by staining a film of dried blood by the Ehrlich, Wright,^ or Zolhkoffer'' stains. The apphcation of this differential leukocyte- count to surgical diagnosis will be referred to on page 725. ' "Annals of Surgery," April, 1906. ^ Cabot: "Clinical Examination of Blood." ^ Cabot: " Clinical Examination of Blood." ^ Sahli: "Diagnostic Methods." •i6 METHODS OF EXAMIXATIOX. OPSONINS AND THE OPSONIC INDEX. The school ot\- ^letchnikoff beheves that the leukocyte is the only element of the blood actively concerned in the phagocvtosis of micro- ^ 9 f 9 e Fig. 477. — Thoma-Zeiss Blood-cootting Apparatus. A, Melangeur; B, coundng-chamber, seen from above; C, profile of" counting-chamber: D, microscopic pic- mre of a portion of ruled field with "blood-cells; £, white counter. organisms. It attributes everything to the white blood-corpuscle, and does not consider that the blood-fluid takes any active part in the phe- nomenon. In the early part of 1903, Wright and Douglas, of St. AIary"s Hospital, London, approached the problem of phagocytosis. They separated OPSONINS AND THE OPSONIC INDEX, 717 the corpuscular from the fluid elements of the blood. That is to say, they obtained leukocytes suspended in a neutral medium instead of in the blood-plasma, and the blood-plasma (or blood-serum) free from leukocytes or erythrocytes. They prepared also an emulsion of staphy- lococci in normal salt solution, and found that, if they brought together only the leukocytes and the staphylococci, practically no phagocytosis occurred, but that the addition of blood-plasma (or blood-serum) to the leukocytes and the staphylococci effected some change, so that phagocytosis did occur. The obvious deduction was that the leu- kocyte by itself was impotent, and further that the blood-plasma con- tained some substance which was essential to the attainment of phago- cytosis. Using ingenious methods of their own devising, they investigated the blood-plasma in order to determine the characters of this phagocytic element, and the following are the most important of their conclusions: 1. The substance, so essential to phagocytosis, does not act upon the leukocytes (as a stimulant to the leukocytes, for example), but it combines with the microorganisms and prepares them for phagocytosis; hence the name opsonin, from opsono, I cater for, I prepare victuals for. The conception of their mode of action is that the opsonins are carried in the lymph to the nest of microbes which are responsible for the morbid process ; that they chemically unite with the microorganisms, and that then, and not until then, the leukocytes have the power of enveloping and destroying these microorganisms. Thus it follows that the amount of phagocytosis which is observed is a measure of the quantity of opsonins present in any particular plasma, and does not represent the vital activity of the leukocytes. 2. The opsonins in a normal serum are almost completely destroyed by heating for ten minutes at 60° C. 3. The opsonins have been shown to be distinct from the bacter- iolysins, the agglutinins, and the antitoxins. Moreover, as shown by Bulloch and Mestern, the opsonins have a high degree of specificity. For example, the blood of a person may contain half the normal quantity of opsonins necessary to combat a tuberculous infection such as' tuberculous cystitis, and yet contain a normal amount of opsonins that have to do with an invasion of staphy- lococci, such as causes furunculosis. Wright and Douglas have shown b}- a striking experiment how invariable a factor the leukocyte really is. They obtained leukocytes both from an immunized patient and also from a normal individual. To a specimen of each of these they added some normal serum, and 7l8 METHODS OF EXAMINATION. also some staphylococci, and allowed phagocytosis to take place. They then found that in the presence of normal serum the leukocytes of the immunized patient took up just as many staphylococci as the normal leukocytes in the presence of the same normal serum. They next took two portions of a suspension of normal leukocytes to which had been added some staphylococci, and mixed with one of these portions some serum from the immunized patient, and with the other some normal serum, and allowed phagocytosis to take place. They then found that the leukocytes, to which had been added the serum from the immunized patient, took up about one-half as many staphylococci as did the leu- kocytes to which the normal serum had been added. This affords striking testimony that the leukocyte is an indifferent or a constant factor in the phenomenon of phagocytosis. The amount of phagocytosis observed, therefore, represents the quantity of opsonins present in the blood. So far as we can tell at present, the plasma has nothing to do with the "quahty" of the leukocytes. Technic. — If we wish to measure the quantity of opsonins present in the blood of a man suffering from furunculosis, which is almost always due to the staphylococcus pyogenes, we require : 1. A drop or two of blood from the patient, and a drop or two from a normal person, from each of which we can easily obtain sufficient serum for our estimation. 2. An emulsion of staphylococci in salt solution. 3. Leukocytes washed free from their plasma. We draw up in a capillary pipet equal quantities of the patient's serum, the staphylococcus emulsion, and the leukocytes; thoroughly mix all three, and having sealed the mixture in the capillary tube, place it in an incubator at 37° C. With a second capillary pipet we again carry out precisely the same operations, except that instead of the patient's serum we use normal serum. This is incubated for the same length of time. An ordinary blood-film is made from each tube at the expiration of the fifteen minutes' incubation. These films are appropriately stained, and then examined microscopically with an oil-immersion lens. . Numerous leukocytes are seen, in the protoplasm of which lie few or many staphylococci. The number of staphylococci, taken up by say 40 leukocytes, is counted. Let us say that in the film prepared with the patient's serum we count 80 staphylococci in the 40 leukocytes. The average per leukocyte is then f-jj or 2. This figure is known as the "phagocytic index" of the leukocyte. We then count the number of staphylococci taken up by the 40 leukocytes in the film prepared with the normal scrum; let OPSONINS AND THE OPSONIC INDEX. 719 US say we count i6o staphylococci; if we divide -j'V^- we get the "normal phagocytic index" for this particular experiment, namely, 4. In each of these preparations the leukocytes and the emulsion of staphylococci are constant factors; the only variable factor is the blood- serum. The amount of phagocytosis depends upon the quantity of opsonins present. It follows, therefore, that the comparison between the two phagocytic indices above recorded, is a comparison between the quantity of opsonins present in the blood-serum of a diseased person and in that of a normal person. The actual ratio in this case is 2 : 4 or 0.5 : i ; the latter figure is the normal "opsonic index," and 0.5 is the abnormal opsonic index of a patient who is the subject of a staphylococcus infec- tion, namely, furunculosis. When we say that a patient has an opsonic index of 0.5 to staphy- lococcus, we mean that his blood-plasma contains but half the normal quantity of those opsonins which are essential to combating a staphy- lococcal infection successfully. Moreover, it seems probable that this deficiency was antecedent to the infection or, in other words, it has made the infection possible. The Opsonic Index : Bacterial Infections. — Certain generah- zations have emerged from the investigation of numerous cases. 1. If the bacterial infection be strictly locahzed, the opsonic index of the blood, as concerns the particular microbe causing the infection, is below normal. For example, the blood of a patient who is suffering from furunculosis will probably show an opsonic index of about 0.6 to the infecting microorganisms, that is, to the staphylococcus pyogenes; or, again, the blood of a patient who is suffering from tuberculous glands in the neck will probably show an opsonic index of about 0.7 to the tubercle bacillus. In each case, the patient's blood is compared with the blood of a normal man. 2. The second generahzation has to do with those infections which are not strictly locahzed. In such cases the opsonic index will be found high at one time and low at another; that is, the opsonic index in sys- temic infections tends to fluctuate from high to low. This character- istic is well shown in cases of acute pulmonary tuberculosis. These two generalizations are of primary importance both as con- cerns the diagnosis and the treatment of bacterial infections. 720 METHODS OF EXAMINATION. LEUKOPENIA, LEUKOCYTOSIS, AND HYPERLEUKOCYTOSIS, By the term leukopenia is understood a state of the blood in which there is a decrease in the number of white corpuscles. Leukocytosis means an increase of white corpuscles. For clinical purposes it is advisable to consider 10,000 as the extreme limit of ordinary normal leukocytosis. The term hyperleukocytosis is used by some to indicate any counts in excess of 10,000. By the majority of surgeons, the term leukocytosis is used to indicate any increase of white corpuscles above the normal. Leukocytoses are either physiologic or pathologic. In the latter the polynuclear neutrophile cells predominate. Leukocytosis in inflammation is regarded as an index of reaction, rather than of the absolute severity of an infection. As Sondern says, "Good resistance on the part of the body will produce pronounced leukocytosis, even in slight infections. Poor resistance produces little leukocytosis in slight and none at all in severe infections." Physiologic Leukocytosis. A normal increase may occur under the following conditions: 1. During digestion. 2. After exertion or a cold bath. 3. During pregnancy, parturition, and the puerperium. 4. In new-born children (up to 30,000). The leukocytosis of digestion begins about one hour after a meal, and reaches its maximum (a 30 to 40 per cent, increase) in about three to four hours (Rieder). Considering the comparatively shght digestion leukocytosis, any great degree of pathologic leukocytosis can be recog- nized, even during digestion. Leukocytosis occurs after the administration of ether and after operations as a transitory condition. Pathologic Leukocytosis, In the Infectious Diseases. — Pneumonia. — A leukocytosis reach- ing as high as 50,000 to 60,000 is quite, common in this disease. The leukocytosis is composed of polynuclear neutrophiles. A normal leukocyte-count with a relative increase of the polynuclear neutro- philes, indicates a severe infection and reduced resistance. Typhoid Fever. — In this condition a normal leukocytosis or even a leukopenia is the rule. This is of great aid in distinguishing typhoid from pyogenic infections. Complications which cause a rapid increase in the number of white LEUKOPENIA, LEUKOCYTOSIS, AND HYPERLEUKOCYTOSIS. 7 21 corpuscles are perforation, suppuration, cystitis, parotitis, pulmonary complications, nephritis, thrombosis, and cholecystitis. Acute Articular Rheumatism. — In uncomplicated cases of this disease there is usually a slight polynuclear neutrophilic leukocytosis (about 15,000), which persists as long as there is fever and exudation. Meningitis. — In suppurative meningitis there is always a marked leukocytosis, while in tuberculous meningitis the leukocyte-count may be normal or up to 20,000. Absence of leukocytosis points to tubercu- losis, but its presence does not exclude it. Scarlet Fever.— In this condition the blood shows a leukocytosis with high eosinophiles, which serves to distinguish this eruptive fever from septic rashes, etc., in which the polynuclear neutrophiles predomi- nate and the eosinophiles are relatively low. Erysipelas has a very high leukocytosis of the typical septic variety, namely, a great increase in the neutrophiles. Septicemia is characterized by a rapid development of severe anemia. There is usually a marked leukocytosis, except in some very mild cases, and in severe, rapidly fatal cases. Blood-cultures may contain the causal organism. Local abscess formation usually shows a leukocytosis. Illustrations of such a localized pus formation are a felon, gum boil, external cutaneous abscess, genital abscess, parotic abscess, sub- phrenic abscess, infections in the neck, etc. Special Varieties of Abscess Formation. — Appendicitis. — In tliis condition the leukocyte- count affords valuable aid for us both as to the diagnosis of the condition, as well as to the stage of the pathologic process. The count should be made at regular intervals, say every hour or two, in all cases, and compared with the symptoms and general condition of the patient. The foUomng are general conclusions from actual cases, according to Cabot : 1. There are no changes in the red cells, except the anemia of chronic cases. 2. Coagulation slow, but the fibrin is always increased in pus cases.- 3. As in all infections, the "very mild and very septic cases show no leukocytosis. 4. Catarrhal appendicitis is rarely accompanied by leukocytosis. An increase from 12,000 to 14,000 is a rare exception. 5. An increasing leukocytosis is an evidence of a spreading process. It should be closely watched and never disregarded. This is of far more significance than'the actual niunber of cells. 46 / 722 ■ METHODS OF EXAMINATION. 6. A low count, 8,000 to 11,000, means one of several things: {a) A mild case. (b) A very severe case in which the resistance of the organism is diminished. (c) An abscess thoroughly walled off. After the abscess has become walled off the count usually remains stationary or shghtly decreases. If the count rapidly increases after such a condition, it means that the abscess has ruptured into the perito- neal cavity. Such a rupture may not, however, be accompanied by an increase, but sometimes by a rapid fall of the leukocyte-count. 7. In the majority of cases the abscess is not completely walled off, and a moderately fluctuating leukocytosis is found. When the leukocytosis increases slowly and steadily, the case is increasing in severity, as a rule. When a leukocytosis of 18,000 to 25,000 is maintained, it means a localized large abscess. 8. Size of leukocytosis: (a) Catarrhal, usually below 12,000. (b) Acute diffuse appendicitis without pus, 11,000 to 22,000. (c) Gangrenous appendicitis, usually 20,000 or more. (d) When pus distends the appendix the count is high, 20,000 or over. When an acute perforation occurs into the free peritoneal cavity, the leukocytosis may fall temporarily; if a reaction on the part of the body takes place, a rapid increase follows; if no reaction takes place, there is no increase. Differential Diagnosis. — The leukocytosis of appendicitis will difl'er- entiate the following conditions : (a) Intestinal colic and the crises of locomotor ataxia. (b) Impaction of feces. (c) Gallstone colic and renal colic, if no infection is present. (d) Ovarian and pelvic neuralgic pains. (e) Floating kidney. (/) Extrauterine pregnancy — this does cause a leukocytosis at times, however. Acute and Chronic Salpingitis and Pelvic Peritonitis. — These cause the same changes as found in appendicitis, and the blood-count is of value only in distinguishing them from non-septic conditions. Infection of the Gallbladder and Bile-passages. — Exactly the same may be said of these as of pelvic infection and appendicitis. The blood is only of value to estabhsh the fact of infection and pus forma- tion, but is of little value in differentiating it from other abscesses. LEUKOPENIA, LEUKOCYTOSIS, AND HYPERLEUKOCYTOSIS. 723 Osteomyelitis has a high leukocytosis which is extremely valuable in differentiating it at an early stage from rheumatism or the prodromes of infective disease, especially smallpox. Infections of the Serous Membranes. — Pleural, Pericardial, and Peritoneal. — This is almost always accompanied by a leukocytosis. The degree of leukocyte increase is extremely variable, and varies from normal to 40,000, and even higher. It is not always possible to differentiate the serous and dry inflammations from the suppurative, as the latter may not have a higher leukocytosis than other varieties. The leukocyte count is, however, valuable in the following condi- tions : {a) To differentiate peritonitis from (i) obstruction (non-malignant), (2) mahgnant disease, (3) hysteria, malingering, etc. A leukocytosis speaks in favor of an inflammatory process. (b) From tuberculous infection, which has no leukocytosis. Gastro-intestinal Tract. — Gastric ulcer causes an increasing anemia with a moderate leukocytosis. Of diagnostic value excepting in complications. (a) Perforation, a rapid rise in the leukocyte-count is usual. {b) Hemorrhage, often an increase of leukocytosis. In chronic hemorrhagic cases the picture may simulate a pernicious anemia. Duodenal Ulcer. — Same as in ulcer of stomach proper. Acute Gastro-intestinal Affections . — A fairly well marked leukocytosis is the rule. Chronic Digestive Disturbances. — As a rule, no leukocytosis and no digestion leukocytosis. Intestinal Obstruction. — -According to Bloodgood, the leukocyte- count here is valuable. Within a few hours the leukocytes, rise rapidl}'. If obstruction is partial, the counts are between 14,000 and 16,000; if complete, usually 20,000 or more. The higher the count and the shorter the duration, the greater the probabiHty of gangrene. If the count shows 20,000 within the first twenty-four hours, the chances are that gangrene is present. On the second day the count does not change much. Then if gangrene or peritonitis occurs the count begins to fall; otherwise the count remains high until the fourth or fifth dav, when the leukocytes graduaUy fall, whatever the condition of the abdomen. If after three days of obstruction the count is still over 20,000 the prog- nosis is good. If the count is below 15,000 the probability is that gangrene, peritonitis, or fatal auto-intoxication has occurred. Surgical Conditions of the Liver. — The coagulation time of the blood is reduced in all conditions affecting the function of the liver. 724 METHODS OF EXAMINATION. This is especially true if jaundice is present, when the hemorrhage from an operative procedure may be uncontrollable. Usually the cap- illary vessels are the worst ones. Gallstones, when no infection is present, cause little or no change. A sKght leukocytosis is sometimes found. During a colic this may be slightly increased, but, as a rule, not to be compared with the leuko- cytosis of infectious processes. All infectious processes of the liver and bile-passages cause a marked leukocytosis; for example, cholangitis, cholecystitis, abscess, thrombosis, and infections of the blood-vessels. This is valuable in differentiating them from typhoid, grippe, etc., which may simulate these conditions. Diseases of the Pancreas. — Acute pancreatitis and hemorrhagic pancreatitis show a fair increase in the leukocyte-count, which will help to distinguish them from the ordinary pains of indigestion, etc. Chronic pancreatitis shows no such change, a low percentage of hemoglobin being the only help in a diagnostic way that may be present. Urinary System. — Infections cause a leukocytosis. This is the only distinguishing feature, and aids in determining, for instance, when pus is present in calculous obstruction, and helps fix indica- tions for an operation. The same holds true in all kidney and bladder affections. The determination of the functional capacity of the kidneys by means of the freezing-point of the blood will be described elsewhere (see page 747)- Nervous System. — The blood examination is of little value in diagnosing diseases of the nervous system directly, as few characteristic conditions are produced. Injuries, infections, and all suppurations increase the number of leukocytes, so that they help to estabhsh the presence of an obscure abscess, for instance, or differentiate it from a tumor. The leukocyte-, count is of value in detecting malignancy and hysteria in many cases. Malignant Disease. — Blood examinations in malignant tumors sometimes afford substantial aid in locating and determining the rapidity of growth and the degree of malignancy, the presence of ulceration and secondary infection, as well as of repeated internal hemorrhages, when carefully considered together with the symptoms. The blood as a whole shows the picture of a secondary anemia, that is, the reduction in the hemoglobin, and the blood-ceUs are in about the same proportion. Occasionally the blood-destroying power or malignancy of the tumor is so great that the picture of a pernicious anemia is produced. THE VALUE OF THE DIFFERENTIAL LEUKOCYTE-COUNT. 725 In most cases the coagulation time is normal or increased. When sloughing is present, it becomes more rapid. When an inflammatory reaction occurs around the tumor, the fibrin may be greatly increased. The red cells are usually smaller in size, pale, and are easily destroyed. The hemoglobin in cancer cases will average 50 per cent, or lower. The color index is almost invariably below i. The leukocyte changes in cancer are important and depend on the following conditions: I. On the position of the growth. (a) When the tumor is situated in the esophagus or cardia, the leukocytes may be diminished. It is in this situation that the pernicious type of anemia is frequent. When the leukocytes are increased, it is fair to assume the presence of these growths in other locations, or that extensive sloughing is taking place. (b) Cancer of the uterus and of the stomach, especially if hemorrhages are taking place, show a high leukocyte-count. (c) Malignant tumors of the kidney, thyroid, and pancreas almost always cause a high leukocytosis. II. Size. Everything else being equal, tumors of the parenchy- matous organs and viscera cause greater leukocytosis than the slower growing epitheliomatous and scirrhus varieties. For example, cancers of the skin, lip, scirrhus of the breast, etc., cause a lov/ leukocyte-count, while tumors of the liver and kidney produce very large ones, as these tumors, as a rule, grow to be of large size. III. Cancer of the bones and blood-forming organs may give a blood-picture depending on the blood-function of these organs. For instance, large numbers of myelocytes, eosinophiles, and intermediate cells may be present, in some respects simulating leukemia, so offering valuable aid in locating metastasis in bones, etc. Sarcoma. — The blood in this condition is of about the same impor- tance as in carcinoma, with the exception that the changes, as a rule, are greater. THE VALUE OF THE DIFFERENTIAL LEUKOCYTE-COUNT. The paper of Gibson^ previously referred to (page 715) is a valuable contribution to the value of this diagnostic method. He believes that the real value of the polynuclear count lies in "//«e relative dis pro portion of the polynuclear percentage to the total leukocytosis.''' He believes that ''with a moderate rise of the total leukocytosis there should be, in ' "Annals of Surgery," April, 1906. 720 METHODS OF EX.UIIXATIOX. favorable cases, a moderate rise of the polynuclear cells only, showing that the infection is localized and absorption is limited. On the other hand, if there is only a moderate leukocytosis with a notable increase in the polynuclear cells, it indicates almost unquestionably that there is either a severer form of lesion or less resistance to absorption, or that both conditions exist." His conclusions will be quoted in full.^ The differential leukocyte-count is of value chiefly in indicating fairly consistently (i) the existence of suppuration or gangrene, as evidenced by an increase of the polynuclear cells disproportionately high as compared to the total leukocytosis. (2) The greater the disproportion, the surer are the findings, and in extreme disproportions the method has proved itself practically infallible. (3) As the relative disproportion between the leukocytosis and the percentage of polynuclear cells is of so much more value than the findings based on a leukocyte-count alone, this latter method should be abandoned in favor of the newer and more reliable procedure. (4) The negative findings, showing no relative increase or even an actual decrease of the proportion of the polynuclear cells, while of less value, shows with rare exceptions the absence of the severer forms of inflammation. (5) In its- practical applications, the method is of more frequent value in the interpretation of the severity of the lesions of appendicitis and their sequela. Value of the Ordinary Leukocyte-count in Differential Diag- nosis. — I. When we are dealing with an obscure, deep-seated disease when hemorrhage can be excluded, the presence of a persistent leukocytosis suggests suppuration or malignant disease, rather than tuberculosis or syphilis, for example, and excludes any simple func- tional or hysterical affection. The absence of leukocytosis, however, does not exclude malignant disease, though it makes suppuration very unhkely. II. Between malignant disease and suppuration, if the other signs and symptoms do not decide, there may be nothing in the blood to decide. In decided pyemia we may get pyogenic cocci in the blood by culture, but a negative result would not exclude a suppurating focus. The reaction of iodophilia may help to decide the presence of pus, also the increase of fibrin in the blood speaks for the presence of pus. III. Between malignant disease and hemorrhage, a marked anemia favors hemorrhage, as the anemia of cancer is slow to develop. The leukocytes give no special aid. ' For further details, the reader is referred to the original article. THE VALUE OF THE DIFFERENTIAL LEUKOCYTE-COUXT. 727 IV. Between cancer and ulcer of the stomach, if there has been no recent hemorrhage, leukocytosis favors cancer, but its absence is of no weight either way. In cancer the hemoglobin steadily decreases, while in ulcer it fluctuates — increasing between hemorrhages, and dropping immediately after one. The presence of a digestion leukocytosis speaks for ulcer, but if any degree of catarrh and glandular degeneration is present it would also be absent in ulcer. V. Between cancer of the liver and bile-ducts, on the one hand, and simple gallstone coHc or obstruction, on the other, the presence of a leukocytosis favors cancer, and we must bear in mind that gallstones with cholangitis may raise the leukocyte-count as much or more than in cancer. Simple cysts or echinococcus cysts cause no leukocytosis, nor does syphiHs of the Hver. VI. The appearance in the blood of large numbers of eosinophiles, myelocytes, and nucleated rods will arouse the suspicion of metastasis in the bones. VII. If the leukocytosis disappears with the removal of the growth and then reappears, we may look for recurrence of the growth. VIII. A steadily increasing leukocytosis in a case of malignant disease points to a rapidly growing tumor or the occurrence of metastasis. IX. Between malignant disease and pernicious anemia, the diagnosis will rest on the following points : ALiLiGNAKT Disease. Pernicious Anemia. Color index and volume index. .Low — less than i. Usually above i. Leukocytosis Usually increased. Diminished. Lymphoc}'tes Relatively decreased. Increase in active num- ber. Average size of red cell Usually below normal, 7.5. Often increased, and great variation in size. Nucleated red cells If present, the normoblast Normoblasts the minority type predominates. — megaloblasts fre- quent. X. Between a malignant "and a benign tumor, the presence of a leukocytosis will speak against its being benign. XL When we suspect a tumor and no actual increase in the whole count is present, the increase of the polymorphonuclear variety will have the same significance as a leukocytosis. Tuherculosis in a general way may be stated to cause a gradual loss of hemoglobin and red cells, producing the typical secondary anemia. 728 METHODS OP EXAMINATION. The leukocytes are usually not Increased when secondary infection is absent, and this is valuable in diagnoses. There are many exceptions to this rule, however, such as: Meningeal tuberculosis — leukocytosis 7,000 to 30,000. Bone tuberculosis — often a shght increase. Genital tuberculosis — a leukocytosis is rather the rule. Syphilis. — The blood-findings offer httle information to the surgeon for diagnostic purposes — except possibly the fact that the increasing lymphocytosis would indicate a late stage and its non-contagious stage. PERNICIOUS ANEMIA. {a) Red blood-cells 1,200,000 per cu. mm. (b) White blood-cells much below 7,500 per cu. mm. (c) Hemoglobin variable — relatively increased, very often color index high. {d) Deformity in shape and size of red blood-corpuscles frequent. {e) Red cells stain irregularly (polychromatophiha). (/) Megaloblasts more numerous than normoblasts. {g) Lymphocytosis. Must be distinguished surgically from: 1. Pernicious type of anemia of mahgnant tumors. In some cases absolutely impossible from the blood alone, but usually a microphitic increase is present with a low color index. 2. From anemia produced by tuberculosis and very chronic suppu- ration. 3. Acute suppuration will show a leukocytosis, low hemoglobin amounts, low color index. 4. Chronic hemorrhage — as from piles, stomach ulcers, etc. Not always possible, but picture of blood will approach more nearly that of a secondarv anemia. LEUKEMIA. Characteristics of blood: I. Myeloid leukemia. {a) Red cells about 3,000,000 — nucleated cells very numerous. (&) White cells about 450,000, of which (c) Myelocytes form about 30 per cent. {d) Every possible form of white cell intermediate between the ordinary varieties is to be seen. (Polymorphous blood.) THE ESTIMATION OF BLOOD-PRESSURE IN SURGICAL CASES. 729 2. Chronic lymphatic leukemia. (a) Red cells about 3,000,000 or lower, nucleated cells rare. (b) White cells about 300,000, of which (c) Small lymphocytes form over 90 per cent. (d) Myelocytes and eosinophiles are rare. 3. Acute lymphatic leukemia. (a) Red cells much diminished, nucleated cells rare. (b) Large forms of lymphocytes predominate, often degenerated. (c) Neutrophiles and eosinophiles very scanty. The above blood-picture will serve to distinguish leukemia from other diseases causing splenic and glandular enlargement, as well as from tumors simulating such enlargements : 1. Hodgkin's disease. 2. Tumors of spleen and vicinity (kidney and retroperitoneal lymph- nodes). 3. Enlargement of lymph-nodes from tuberculosis, syphilis, malig- nant disease. 4. Hydronephrosis. 5. Large leukocytosis from any cause. 6. Chronic malaria. 7. Amyloid disease. THE ESTIMATION OF BLOOD-PRESSURE IN SURGICAL CASES. Blood- pressure. — The determination of blood-pressure has assumed such practical importance that every surgeon should be famiHar with the use of the appropriate instruments. Of the latter there are a number of different lands. The one which is most easily employed at the bedside or operating table is the Riva- Rocci sphygmomanometer, as modified by Cook and Briggs (see Fig. 16). For details as to its use, the reader is referred to special treatises on the subject of blood-pressure. Experimental and clinical observations by Crile, Cushing, Cook, Janeway,^ and others have shown that the estimation of blood-pressure is of great value from both a diagnostic and therapeutic standpoint in the following surgical condi- tions : During Surgical Operations.— To be of value a determination should be made every five minutes, the pulse-rate being recorded on a chart. Ether, even in large amounts, seldom produces a significant 1 Janeway: "Clinical Study of Blood-pressure." Cook: "Jour. Amer. Med. Assoc," p. 1 199, 1903. 73° METHODS OF EXAMINATION. fall in blood-pressure. Chloroform is usually accompanied by a marked fall in blood-pressure in 69 per cent., and a moderate fall in 18.9 per cent, of the cases, according to Blauel. An initial rise in blood-pressure follows any cutting operation, while the irritation of large nerve-trunks causes a much greater reflex rise of blood-pressure. The opening of the peritoneal cavity is at first followed by a sharp rise, but there is a subsequent fall in blood-pressure dependent on the duration of the operation and the amount of exposure and manipulation of the viscera. Blood-pressure in Surgical Accidents and Diseases. Hem- orrhage. — The loss of any considerable volume of blood, either during an operation or as the result of an accident, causes an immediate fall in blood-pressure. It is very difficult to draw any deductions after an accident as to whether the low amount of blood-pressure is the result of hemorrhage or shock. This uncertainty is due to the fact that the acute anemia causes a considerable degree of shock. One distinction is, however, present, viz., that if the bleeding is checked or ceases spon- taneously, and is not succeeded by shock, the blood-pressure will grad- ually rise. This latter condition is due to the fact that there is a definite physiologic tendency for the blood-pressure to return to its level. Collapse and Shock. — The term shock, according to Crile,^ should be hmited to the condition (page 526) in which there is a gradual fall in blood-pressure. The term collapse should be confined to those cases in which the essential phenomenon is a sudden fall of blood-pres- sure, due to hemorrhages, injuries of the vasomotor center, or cardiac failure. The lowering of the blood-pressure in shock is due to repeated afferent impulses acting on the vasomotor center and causing exhaus- tion of the latter. In operations involving handling or long exposure of abdominal viscera, after subcutaneous injuries of the thoracic or abdominal viscera, or in peripheral injuries such as follow a crushing force, there is a steady fall in blood-pressure as a symptom of shock. Head Injuries. — The marked rise in blood-pressure, as an expres- sion of increased intracranial tension in head injuries or diseases, has been referred to (page 38). The estimation of the blood-pressure is of considerable value in connection with all other general and focal symptoms. A low blood-pressure, according to Kocher^ and Gushing,^ may be ' "Boston Medical and Surgical Jour.," March 5, 1903. ^ Nothnagel's "Spec. Path. u. Therap.," vol. ix. ^ " Amer. Jour, of the Med. Sciences," 1902 and 1903. CYTODIAGNOSIS. 73I present in concussion and in the paralytic stage of compression. A marked rise in blood-pressure follows any lesion, wliether traumatic or non-traumatic, which produces an increase of the intracranial pressure and resultant anemia of the medulla (page 38). The writer makes it a practice to have systematic blood-pressure measurements made at regular intervals (every half hour) in cases of head injuries. A high blood-pressure is present in (a) acute compression of the brain from splinters of a depressed fracture, or from an extradural or sub- dural clot; (b) in fractures of the base of the skull; (c) in cerebral apoplexy. A high and rising blood-pressure indicates progressive failure of circulation in the medulla and an increasing hemorrhage. Hemorrhage into the anterior fossa of the skull has the least, while that into the posterior fossa has the most, effect on general blood- pressure. Uremic coma is accompanied by increased blood-pressure, so that this symptom cannot be utilized to differentiate uremic from apoplec- tic coma. Acute Peritonitis. — The arterial tension rises in the early stages of acute peritonitis, and this sharp rise in blood-pressure may be of great value in making a diagnosis of typhoid perforation and other forms of incipient peritonitis. CYTODIAGNOSIS. This method of examination is of increasing interest to surgeons. It consists in the study of the character and number of the cellular constituents of exudates and transudates. For the technic of this method the many special text-books should be referred to.^ The conclusions obtained should never be employed as the sole means of making a diagnosis. It is and must always remain a single symptom. Cytodiagnosis is, however, of aid in the following fluids: Cerebrospinal Fluid. — In epidemic cerebrospinal meningitis the fluid is at first clear, and gradually becomes more turbid. Polynuclear neutrophiles predominate in all stages, but in some the lymphocytes are in the majority. In tuberculous meningitis, either mononuclears or polynuclears pre- dominate, usually the former. All forms of purulent meningitis of trau- matic or metastatic origin show microorganisms and typical pus cells. ' Sahli: "Diagnostic Methods." 732 . METHODS OF EXAMINATION. In tetanus and in cerebral tumors there are no cells in the cerebro- spinal fluid. These findings enable one to make a differential diagnosis of acute spinal meningitis from tetanus, or from the cerebral symptoms of a tumor, or from the acute infectious diseases. Pleural Fluids. — i. A predominance of lymphocytes means a tuberculous effusion. 2. A predominance of polynu clear neutrophiles means an effusion of an acute infectious origin. 3. A large number of endothehal cells, occurring especially in sheets or plaques, means a mechanical effusion or transudate. 4. In neoplasms of the pleura. Free tumor cells are often found in bunches. The cells are difficult to distinguish from leukocytes and endothehum, because both of the latter are also present in the exudate of a neoplasm. Karyokinesis speaks for a neoplasm. There have been too few observations of joint, peritoneal, or pericar- dial fluids to draw anv conclusions. EXAMINATION OF THE SPUTUM, STOMACH CONTENTS. URINE, AND FECES. The importance of a thorough examination of these secretions and excretions cannot be too strongly emphasized. They are of the greatest value from a diagnostic standpoint. The results have been discussed in connection with the various in- juries and surgical diseases in the preceding chapters. It is beyond the scope of a book of this character to describe the technical procedures. For the latter the reader is referred to the many standard treatises de- voted to this purpose (Sahli, Boston, Simon, von Jaksch, etc.). THE NEWER METHODS OF DIAGNOSIS OF RENAL LESIONS. Ureteral Catheterization and Examination with Sounds, Etc.^ The urine from each kidney can be collected separately by means of elastic catheters inserted into the ureters. The tip of the catheter should only extend beyond the vesical end of the ureter. If the catheter has not been passed into the pelvis of the kidney, urine is ejected from the distal (i. e., external) portion of the catheter at intervals, just as it is normally from the ureteric opening into the bladder. If the tip of the ^ The sections upon Ureteral Catherization and Cystoscopy were written by Dr. Gustav Kolischer, of Chicago. THE NEWER METHODS OF DIAGNOSIS OF RENAL LESIONS. 733 catheter extends into the pelvis of the kidney the urine drips out in a continuous stream. At times the insertion of a ureteral catheter is followed by a temporary reflex anuria. The flow of urine through the catheter may also be obstructed by a plug of mucus or pus, arrested in the catheter. This can be overcome by injecting some sterile water into the catheter. If blood appears in the urine which is being collected, the tip of the catheter should be pushed a little higher up, so that it is possible to exclude an injury to the ureteral mucous membrane through the passage of the catheter. In case it should be impossible to cathe- terize one ureter, or if it be considered undesirable to catheterize the ureter of the presumably healthy side, the so-called balloon catheter is employed. This is a ureteral catheter whose eye is covered by a very thin rubber membrane. After this catheter is inserted into one ureter, the rubber is inflated by means of a syringe, and after the inflation is finished the distal end of the catheter is tied. In this way the catheterized ureter is plugged, and the urine coming down from the opposite kidney is collected in the bladder and can be drained out by an ordinary cath- eter. Previous to the act of collecting a specimen, the bladder must be carefully irrigated, and then emptied. If it is necessary to make a differentiation between a complete severing or transverse section of a ureter and a ureteral fistula, which involves only a part of the ureteral wall, ureteral catheterization will solve this problem in the following way: In case of a complete lack of connection between the distal ureteral stump and the proximal end of the ureter, it will be impossible to pass the catheter beyond the region of the fistula, and at the same time the distal opening of the catheter will remain dry. If only a parietal, partial lesion of the ureter is present, quite often the catheter will slip over this place beyond the region of the superficial fistulous opening, and urine will come down through the catheter. The emptying of a fluctuating tumor occupying the renal region, through the insertion of a ureteral catheter inserted high up, will classify this tumor as a nephritic one. In case it should be desirable to measure the length of that portion of the catheter which is inserted into the ureter a so-called zebra catheter is employed. This is a catheter whose surface is marked in turn by yellow and black spaces, each being one centimeter long. By counting the number of these fields, which dis- appear into the ureteral opening, the desired measurement is secured. An additional aid in making the diagnosis of concretions deposited in the renal pelvis may be had by the use of the ureteral catheter. The catheter is introduced until its tip rests in the renal ]:)elvis; then 734 METHODS OF EXAMINATION. sterile water is injected through the catheter into the renal pelvis. If this injection is followed by the appearance of blood in the urine, which has been taken from this kidney, this phenomenon points very strongly to the presence of concretions, whose movement as the result of the in- jected stream of water produced hemorrhage. If a wax-tipped ureteral catheter, after being withdrawn from the renal pelvis and ureter, shows scratches on its wax coating, absolute evidence is furnished of the exist- ence of concretions. In deciding upon the patulency of a ureter, either solid sounds or catheters, strengthened through the insertion of a metalhc mandrin, must be used. All these instruments should be well lubricated with glycerin before using. It must be remembered, however, that the mere fact that a catheter or a sound meets with resistance somewhere in the ureteral canal, does not prove the existence of some permanent obstruc- tion. Very often the catheter is simply caught in a mucous fold, or the mucosa is, by virtue of some inflammation, swollen to such an extent as to impede the smooth progress of the catheter-tip. This is especially true for the vesical part of the ureters. In case the catheter does not progress smoothly and warps, several methods can be employed in order to exclude errors in the above-mentioned sense. Glycerin of vaselin oil is injected through the catheter in the ureter, and then a thicker catheter is employed, the tip is repeatedly twisted around, so as to extricate it out of an interfering fold of mucosa ; in case the ureteral opening should show signs of inflammation, a few drops of adrenalin solution are injected into the vesical end of the ureter, so as to cause the mucosa to contract and thus reduce the swelling. The diagnosis of a stricture of the ureter can only be made if a thinner catheter or sound passes through the whole length of the ureter, after a previously employed larger instrument has failed to do so, and if the sound, after having passed through the region of apparently reduced lumen, gives the examining hand the distinct impression of being "engaged." The diagnostic range of ureteral catheterization can be amplified by its combination with radiography (Fig. 4,78). If a metalhc sound (lead wire) or a catheter armed with a metallic stylet is introduced into the ureter and renal pelvis, and an :v-ray picture is taken while the catheterizing instrument is in situ, the shadow of the wire will appear in the x-ray picture. The following information can thus be gleaned: The shadows of the wire mark the course of the ureter. In case the renal pelvis should be enlarged (dilated) the proximal end of the wire adjusts itself to the THE NEWER METHODS OF DIAGNOSIS OF RENAL LESIONS. 735 shape of the pelvis, outhning its extent by curhng up on the inner surface of the pelvis. In case one or more concretions are present in the kidney, their topographic position can be determined; if the shadow of the wire-tip is in direct connection with the shadow of the concretion, the diagnosis of a pelvic stone is made; if the shadow of the concretion appears inside the shadow of the kidney at a distance from the wire-tip, the diagnosis of a concretion inside of the renal parenchyma is made; its exact location can be determined by judging the distance of its shadow from the shadow of the wire-tip. Fig. 478. — liADiOGRAPH OF Suspected Renal Calculus with Sound in Ureter (E. Hurry Fenwick). The arrow points to a shadow which was shown to lie outside of the ureter, the latter being filled with a shadowgraph bougie. The shadow proved to be a patch in an atheromatous artery. If small round shadows appear in the picture somewhere alongside the course of the ureter, it can be determined whether these shadows are produced by ureteral concretions or not. Ureteral concretions will necessarily produce shadows that are in intimate relation to the shadow produced by the wire lying in the ureter. Other conditions which produce shadows, not in close relation to the sound, are calcified mesenteric lymph-nodes, phleboliths in the veins of the pelvis, areas of ossification in the ligaments of the pelvis. /o 6 ilETHODS OF EXAillXATIOX. If the shadow of the wire leads directly into the shado^^w outHne of a tumor, the connection of tliis tumor with the kidney is estabhshed. The collection of urine separately from each kidney renders it possible to determine Avhich kidney or whether both are diseased, (a) by the microscopic and chemical analysis of the collected specimens; and (b) it furthermore enables the examiner to investigate the func- tional capacity of either kidney. Cystoscopy. Cystoscopy is the ocular inspection of the inner surface of the urinary bladder, accomplished by means of appropriately constructed instru- ments. Under special conditions the vesical end of the posterior urethra also becomes accessible to inspection. ISIodern cystoscopy rests upon the follo"UTtig principles: (a) The discus is dilated by means of the inflation of air, or through a transparent watery fluid which has been injected into the bladder. (b) Through the insertion of an incandescent electric light into the bladder, and the enlarging of the virtual picture, either by a lens inserted in the instrument used or through the combination of a prism and lens by means of a telescope-Kke arrangement (Figs. 479 and 480). The cystoscopes most often used belong either to the group which furnish inverted pictures or they belong to a second group wliich furn- ish a direct view, that is, an upright picture. To the iirst-mentioned class of instruments belongs the so-called retrospective cystoscope, wliich by a pecuhar optic arrangement permits the inspection of the internal orifice of the urethra and of the extreme inner part of the posterior urethra. The addition of conducting canals converts the cystoscopes into instruments which can be used for ureteral catheterization and for operative procedures. The second group of cystoscopic instruments includes those wliich furnish a direct view, that is, upright pictures. The addition of con- ducting canals transforms these instruments also into cystoscopes which can be employed for ureteral catheterization and for endovesical opera- tion. In order to determine the topographic location of various lesions we resort to conclusions drawn from (a) the position of the ocular end of the instrument, and (b) from the relation of the lesion under question to certain landmarks on the inner surface of the bladder. A Httle knob soldered to the circumference of the ocular part, in the same sagittal plane as the convexity of the beak, indicates the THE NEWER METHODS OF DIAGNOSIS, OF RENAL LESIONS. 737 position of the cystoscopic window, and thus the location of the object in view. A further more precise determination is furnished by the following intravesical landmarks : 1. The internal orifice of the urethra. It appears under normal conditions as a crescent-shaped fold of dark red color, only shghtly glossy, and of velvety surface. 2. The intraureteric hgament. It presents itself as a small band, Fig. 479. — Brenner's Ureter-cystoscope. Fig. 480. — Nitze's Cystoscopes. more or less prominent, running in a transverse direction through the field of view covering the trigonum. 3. The ureteral openings, appearing at either end of the above- described band. 4. The air-bubble, naturally always floating on top of the tilhng fluid, thus indicating the vertex of the bladder. This bubble shows silvery reflexes, is translucent, and in its center the reflex of the incan- descent hght is to be seen; it oscillates according to the respiratory movements. The normal color of the mucosa of the bladder is a light yellow 47 738 METHODS OF EXAMINATION. with a pinkish or grayish tinge, and the ramifications of tlie blood-vessels are distinctly to be seen; the surface of the vesical mucosa is smooth and glossy, and any deviation from one or from several of these conditions points to pathology. The ureteral openings appear normally as fine slits of a somewhat darker color than the surrounding mucosa, only during the ejaculations of urine are these slits transformed temporarily into holes; a ureteral opening of a dark red color or a permanent gaping of the ureteral mouth is pathologic. Cystitis. — Acute inflammation of the mucosa characterizes itself by the change of the normal color to a red of dift'erent shades, and by the disappearance of the blood-vessels in the affected areas; in the adjacent parts, the blood-vessels appear to be injected and dilated. The intensity of the coloring is in proportion to the intensity of the in- flammatory process. In cystitis that occurs in circumscribed patches, areas of mucosa of normal appearance separate the dark spots; if the cystitis is of a general character, large areas appear dark red, without showing any blood- vessels, or the whole surface of the mucosa is dark red, and of velvety appearance. In case of intense inflammation shreds of epithelium are attached by one end to the inflamed areas, and submucous hemorrhages are to be seen in the immediately adjacent parts. Acute gonorrheal cystitis is characterized by the confinement of the process to the trigonum, that appears to be studded with red spots of various sizes; the greatest intensity of coloring is found in the centers of these blotches, the coloring tapering to pink in the periphery of these foci. Chronic cystitis is characterized by the changing of the red color into a more brownish shade, the surface of the affected parts is without any gloss whatever, and the hemorrhagic spots appear to be black. The mucosa is quite often swollen and raised into thick clumsy folds, impressing the inexperienced eye at first glance as neoplastic formations. They can be differentiated from polypi in the following ways: Polypi have not such a broad insertion; polypi are, at least at their ends, translucent; and if transillumined show very distinctly their blood-vessels, while folds of the swollen mucosa are absolutely opaque. The products of cystitis in chronic cases appear either as lumps of a whitish appearance and of a frowsy surface, attached to discolored parts of the mucosa, or they cover, formed into membranes, the depen- dent parts of the bladder. THE NEWER METHODS OF DIAGNOSIS OF RENAL LESIONS. 739 In some cases of long standing the chronic inflammation leads to the formation of villous excrescences around the internal urethral orifice and on the adjacent parts of the bladder entrance. These formations remind one of a glove in miniature. They are not transparent, and give distinctly the impression of jelly-like infiltration. Cystitic Ulcers. — They appear in the cystoscopic view as fossettae sunken down into round elevations; their bottom is covered with a grayish coat; the elevations are located in cystic brownish-colored areas; their favorite location is in the trigonum. Tuberculosis of the Bladder. — A. Tuberculous Catarrh or Tuber- culous Parenchymatous Cystitis. — K large area of the mucosa appears to be reddened. The blood-vessels in the involved area are not to be seen, the whole surface being smooth and giving the impression of a gelatinous swelling. Numerous ecchymoses are also to be seen. The inflamed area is extremely sensitive to the touch and the capacity of the bladder is always markedly reduced. This picture, of course, in- dicates only a suspicion of tuberculosis. The final diagnosis can only be made by finding tubercle bacilli in the urine. B. Nodular and Ulcerative Tuberculous Cystitis. — In the trigone one most frec^uently sees nodules of different sizes, varying from the size of a hempseed to that of a lentil. These nodules are of a grayish or yellowish color, surrounded by a dark red margin. Some of these nodules are broken down in the center, so that small ulcers result. Their edges are undermined, raised, and ragged. In more advanced cases, two or three of these ulcers may become confluent, thus forming a larger ulcer of irregular outline. The floor of these ulcerations is covered by pale, irregular granulations, which bleed very easily. If these nodules or ulcers are grouped around a ureteral opening, ■or if the ureteral mouth shows signs of inflammation, if it is gaping, red, and its lips swollen, or, if the ureteral opening forms the central part of such an ulcer, the diagnosis of descending tuberculosis, origina- ting in the kidney, is almost certain. Here again the final diagnosis rests upon finding tubercle bacilli. C. Tuberous Form of Tuberculosis. — We see one or two solitary tumor-like excrescences of various thickness and height protrude from a red, darkened area of the mucosa: The top of such a prominence always carries an ulcer, with ])uffy, ragged edges; its bottom is covered by easily bleeding granulations. This form of tuberculosis preferably appears near the internal orifice or in the vertex of the bladder. Solitary Ulcers. — These ulcers may appear anywhere in the bladder. 740 METHODS OF EXAMIXATIOX. Thev are surrounded by apparendy healthy mucosa of normal color, gloss, and vascular ramification. Their contour is quite round, the edges are sharp, and the floor is covered with sohd red granulations. The ulcer is below the level into the mucosa, and it appears as though stamped out of the lining with a sharp die. These ulcers are rare, and appear almost exclusively in young individuals. Edema of the Bladder. — In general edema of the bladder, the mucosa appears to be thrown up into thick clumsy folds. The color, if no acute inflammator}' conditions of the Hning are coexistent, is whitish. I'he blood-vessels are not to be seen. The surface, especially the crest of the folds, appears as if covered with glistening white scum. Circumscribed edema shows limited areas of the mucosa teased apart at the surface, so that the affected part of the mucosa appears hke a flake of wet, white absorbent cotton (retrostrictural edema). Inflammatory tumors, in becoming attached to the bladder waU, produce a certain kind of circumscribed edema, which is pecuhar to the bladder mucosa. On account of the characteristic appearance and the patholog}-, it is called bullous edema. The aft'ected area of the mucosa appears to be covered Avith any number of translucent globuli, whose sizes vary from that of a lentil to that of a large pea. In difl'erent places white flakes, attached by one end to the mucosa, float in the fluid, which has been injected into the bladder. . If these globuli are closely crowded together, the whole affected parts offer the appearance of a cluster of small grapes. The base and the adjacent mucosa appear reddened, quite often wrinkled. If the inflammatorv tumor Avhich has produced the condition pushes the bladder waU into the lumen of the discus, and if a great many of these globuH have burst on account of the tension, the whole afl'ection may be mistaken for a neoplasm. Prostatic Hypertrophy. — Changes in the size and formation of the prostate gland become visible inside of the viscus, and can be diag- nosed through the cystoscope, if the vesical surface of the gland is the main seat of the afl'ection. Any change in the normally crescent-shaped, sharp outhne of the internal orifice, as it appears in the cystoscopic view, points to abnor- malities in the prostate. It is, however, important to miake allowance for an indentation of the urethral canal, if the ocular end of the cystoscope is markedly elevated. THE NEWER METHODS OF DIAGNOSIS OF RENAL LESIONS. 74I If one lateral lobe is enlarged, one side of the circumference appears to be elevated and protruding into the field of view. If such a lateral lobe is considerably enlarged, and grows into the bladder, a hilly prominence in the so-called vesical neck is to be seen. If prostatitis is present the mucosa covering this prominence appears edematous. If both lateral lobes are enlarged, the aspect of the internal orifice is changed into a V-shape. If both lateral lobes grow into the viscus, several prominences elevating the mucous membrane of the trigonum are to be seen. If the median lobe is moderately and uniformly enlarged the crescent-shaped outhne of the internal orifice of the urethra appears to be fiat. If this uniform enlargement reaches a higher degree, the concave outline of the internal orifice is changed into a convex one. If the median lobe becomes pedunculated, and if the upper part of it keeps on growing, the cystoscope reveals a pedunculated valve hanging across the internal orifice. A uniform enlargement of the prostate not only changes the outline of the internal orifice into a straight or even into a convex line, but it also shows the resulting base of the bladder as a deep valley, whose bottom appears dark on account of the shadow. All these findings are more distinctly and markedly seen through the employment of the retrospective cystoscope. In case arteriosclerosis is the cause of the prostatic trouble, thick, rigid-appearing blood-vessels are to be seen meandering through the mucosa covering the prostate; these blood-vessels spring into promi- nence like strands buried in the mucosa. As a rule, we see tiny blood-streams trickhng down from these places, which were touched in introducing and manipulating the cysto- scope. Vesical Calculi. — Bladder stones present themselves in the cvsto- scopic view as well-defined foreign bodies, that distinguish themselves sharply from the bladder wall. As to any conclusions regarding their size, it must be remembered that only at a certain distance (var3-ing according to the lens S3^stem employed) from the window, objects will appear in their natural size, otherwise they become magnified in the cystoscopic observations. Furthermore, if a concretion is so large that it extends beyond the cystoscopic field of view, we only get a constructive picture of the whole stone; but we can always arrive at a pretty accurate conclusion as to the size of the stone if we observe its distance from, or its extension over, the aforementioned landmarks inside of the bladder. 742 METHODS OF EXAMINATION. Further information as to whether a stone is freely movable or partially embedded between folds of mucous membrane, or whether it is encysted to any extent in a diverticulum, can be gained by using a ureteral or operative cystoscope through whose conducting canal we introduce a sound or a forceps. By trying to move the stone or by dislodging it, all points may be cleared up, upon which we desire information. With the aid of the cystoscope, we observe the color of the concretion, the quality of its surface, and its general formation. Phosphates and lime-stones appear as white foreign bodies, which, as a rule, are egg-shaped. Urates show a yellowish color and a round form. Oxalates are either brown, or of a blackish-brown; occasionally they show a black- greenish tinge. Their general formation, as a rule, is rather irregular, their surface is granular, and in marked forms they appear like mulberries. The cystoscope decides very readily whether only one or many stones are present. If we discover facets on the surface of one, this is a strong indication to look for other calculi. If cystitis or traumatic ulcerations are present, we discover these readily by ocular inspection. In a differ- ential diagnostic way, large blood coagula or pus coagula deserve to be mentioned. Blood coagula have quite a characteristic yellow, leathery appearance; their surface is absolutely smooth, much more so than that of any stone. Large masses of pus appear to be strongly light- reflecting, almost white, like small snowballs, and their surface shows a very loose structure. Tumors of the Bladder Wall. — Neoplasms of the bladder appear in the cystoscopic field as protrusions that are attached to the bladder wall at one end, and extend into the lumen of the viscus at the other. This standing out in relief is characteristic of neoplasms. It is very pronounced, if the tumors are pedunculated. If the tumors are attached to the bladder wall by a broad basis it is less pronounced. If a neo- plasm infiltrates the bladder wall, this standing out in relief is least pronounced. In the latter case, a preliminary symptom is quite char- acteristic, viz., when we try to dilate the bladder by injecting water by means of a hand-syringe, we experience an exquisite sensation of rigid resistance. The cystoscopic pictures are very clear and easily recognized and classified if no cystitis is coexistent. The tumor-mass, not showing any blood-vessels, and being of a different color, can be differentiated very readily from the normal mucosa. The impression of something solid is strengthened by the appearance of the shadows that are cast by the tumor over the mucosa. These shadows change their position according to variations in the THE NEWER METHODS OF DIAGNOSIS OF RENAL LESIONS. 743 position of the cystoscopic beak. Swollen, thick mucosa folds may occasionally simulate neoplasms. The following points will aid in distinguishing these swollen folds of mucous membrane from tumors. The folds when swollen are always multiple, which is rather rare in tumors. The folds appear as diffuse swellings, while neoplasms appear to be more sharply defined. Swollen mucosa folds show over their entire surface a whitish, glistening scum. Malignant tumors, as a rule, ulcerate on their surface, and then present on their summit an irregularly shaped ulceration, which almost uniformly bears incrustations. If a neoplasm occurs in a cystitic bladder, or if a neoplasm is ulcerated, a certain method must be employed in order to obtain good views. After the instrument is introduced, it must be kept quiet for a while, so as to give the particles of debris and pus iioating in the fluid a chance to settle down to the most dependent parts of the bladder. The so-called villous polypi or papillomata of the bladder give very beautiful and characteristic views. As a rule, they grow from a common pedicle, which divides into several branches. These show a leaf-like appearance, and float around like water-plants in the fluid which has been employed to fill the bladder. If the light is allowed to pass through these leaves they show quite distinctly long loops of blood-vessels. Some of these tumors show at their edges a fimbriated condition. iVll these tumors are of a benign nature, and contact may produce free hemorrhage. Other tumors imitate the shape of a mushroom. Malignant tumors show, besides the ulceration already referred to, an irregular surface, there being recesses or excavations and hemorrhages in the adjacent mucosa. An extensive phlegmon of the mucosa in its initial stages can hardly be differentiated from an infiltrating cancer in the cystoscopic view. The diagnosis can, however, be made from the accompanying symptoms of each condition. Encrusted tumors may occasionally be mistaken for calculi and vice versa. The employment of an operative cystoscope and the ma- nipulation of the questionable object by a forceps introduced through it will assist in making a differential diagnosis. In rare cases a blood coagulum attached with one end to the bladder wall and floating around with its free end may be taken for a polypus. Close observation of its surface, and the lack of any translucency, even at the edges, will iinally settle the diagnosis. Parasites of the Bladder. — Parasites on and in the bladder wall produce a cystitis of the following character. The cystoscope shows reddish patches disseminated all over the inner surface. Adherent to 744 METHODS OF EXAMINATION. the centers of these foci of inflammation are whitish or yehowish gran- ular areas. These granules are not as flat as the covering of ordinary ulcers, but protrude into the viscus, and show strong reflecting power. These granules are formed by the mycelia of the parasite, whose char- acter must be determined by microscopic examination. Syphilis of the Bladder Wall. — Syphihs of the bladder produces various cystoscopic pictures, according to the luetic lesions present. Condylomata lata (mucous patches) appear as yellowish prominences of the well-kno^^Tl form. Syphihtic ulcers do not differ from those of other infections in appearance. Gummata elevate the mucosa, and after breaking do^Mi show central ulcerations. The diagnosis can only be made positive through antisyphilitic medication. Leukoplakia of the Bladder. — This condition manifests itself in the cystoscopic view by the appearance of white patches, located in the trigonum or at the junction of the base of the bladder to the fundus. These patches are somewhat prominent above the surface of the mucosa, are of oval or circular shape, and vary in size from a diameter of 3 to 6 mm. The surface of these patches appears to be of sohd, dense struc- ture. If these patches are in a condition of reaction, showing a lighting up of a cystitis, they have a scarlet-red small periphery, and the blood- vessels in the adjacent mucosa appear to be injected. Patent Urachus. — In this condition we see at the top of the bladder a round hole, surrounded by a rim of protruding, highly vascularized, smooth, shiny mucosa. The center of this opening is dark. A ureteral catheter introduced into this shadowy center proceeds without any obstruction for several inches in an upward direction. In case inflammation has occurred around tlie opening of the urachus into the bladder, the ring of mucous membrane encirchng the opening appears to be swollen; ribbons of detached epithelial covering project into the lumen of the bladder, and pus flakes are seen to drop from the opening of the urachus into the bladder. In the mucosa adjoining the opening numerous submucous hemorrhagic patches are to be seen. Abnormal Communication of the Bladder with Some Preformed Cavity or Some Perivesical Area of Infection, etc. — The perforation of a pelvic abscess into the bladder is marked in the cystoscopic picture by a bulging of the aft'ected bladder area into the lumen. If the exu- date is still under high tension, this part of the mucosa is covered with edema bullosum. If the tension has considerably relaxed, the mucosa appears to be generally swollen, but, as a rule, a few pearls of circum- scribed edema are to be noticed in the otherwise generally edematous mucosa. THE NEWER METHODS OF DIAGNOSIS OF RENAL LESIONS. 745 The perforation appears as a ragged hole, whose edges are everted. The border is covered with pus flakes and with ribbons of the detached epithehal layer. The adjacent mucosa is dark red, the vascularization is no longer visible. Ecchymoses are numerous, and quite often we see a thin stream of pus running down into the bladder. Pressure on the inflammatory tumor increases the flow of pus into the bladder. The pus accumulates in the trigonum and fundus, and appears there as a white, strongly reflecting mass. The perforation of a pyosalpinx shows a similar picture, but the bladder wall, as a rule, is involved in the inflammatory changes only to a very limited extent. As a rule, no flow of pus into the bladder is to be noticed. Pressure on the pyosalpinx makes corrugated, sausage- shaped strands of pus appear in the perforation. If the pressure is kept up, these strands accumulate and are arranged in loops at the fun- dus, thus giving the appearance of a network of white, strongly reflect- ing strands. The perforation of a dermoid cyst shows similarly an opening sur- rounded by the signs of contiguous inflammation. Either bunches of hair, covered with caseous masses, or parts of the bony skeleton can be seen protruding into the bladder. Vesicorectal fistulas may become the object of cystoscopic examina- tion if the fistula is a tortuous one, or if the rectal fistulous opening is so small that it can easily be closed temporarily by packing. In either case it becomes possible to dilate the bladder for a sufficient length of time to permit a cystoscopic examination to be made. The vesical opening of such a fistula always appears hke a crater, drawn in toward the bowel, so that concentric longitudinal folds of mucous membrane appear. The border of the fistula appears to be smooth and the mucosa tense over it. The signs of inflammatory reaction around the fistulous opening are very slight. Once in a while fragments of feces may be seen adherent to the edges. Vesicovaginal fistulas can be rendered accessible for cystoscopic examination either by clamping together the edges of the communication or by tightly packing the vagina with wet cotton. The vesical opening of the fistula is always surrounded by an in- flamed area of mucosa; the most important feature of this examination is to determine what relation the ureteral openings bear to the fistula. The communication of the bladder with a loop of intestine, as a result of the perforation of an intestinal carcinoma into the bladder, gives quite a striking picture. In the fundus, or in tlic vertex of the bladder anywhere, we see a 746 METHODS OF EXAMINATION. dark excavation of varying size. This recess sliows a double border. In the inner part the smooth mucosa of the intestine, sliiny and pinkish, protrudes into the viscus. In some places we see ulcerated portions of the neoplasm. Irregular craters with a discolored base, their edges ragged, and ribbons of necrosing tissue floating from their periphery, are seen. The outer ring of the edge is formed by the vesical mucosa. It appears to be dark, velvety red, and submucous hemorrhagic patches are to be seen. The adjacent mucosa is characterized by a very dense network of the finest blood-vessels. Hemorrhoids of the Bladder. — Simple dilated large veins appear in the cystoscopic picture as meandering blue strands of various caliber; they quite often protrude above the level of the mucosa. True "hem- orrhoids," that is, well-developed phlebectasias, parietal dilatations, or pockets in the veins, give different cystoscopic pictures, according to their relation to the cystoscopic beak. If the light strikes them from the front or diffusely, they appear as well-defined blue globules with a smooth surface. If they are transil- lumined from behind, they appear as reddish, somewhat transparent globules, that frequently carry a dark center ("phlebohths"). Once in a while a floating-blood coagulum is seen to be attached to the periph- ery of such a nodule. In order to test the functional capacity of the two kidneys, several methods are in use: Chromocystoscopy. Drugs which stain the urine are brought into the circulation after being swallowed or by intramuscular injections. These drugs after a certain length of time (thirty minutes) color the urine. If this coloring is delayed in its appearance, or if the intensity of the coloring is lessened, the kidney is considered to be below par. Methylene-blue can be given by mouth, and for intramuscular injections a 4 per cent, indigo-carmin solution is used. The limitations of this method of chromocystoscopy are obvious. In the first place, we have no sliding scale that would enable us to draw reliable conclusions as to the time the stain appears in the urine or from the intensity of the coloring. It is a matter of experience that normal kidneys show great varia- tions as to both of these points, and that not infrequently diseased kidneys act very promptly as to these signs. The only diagnostic point that can be gained by this method is, if a stained urine is ejaculated from both ureteral openings, then we are dealing with two functionating kidneys and, considering the rarity of a horseshoe kidney, we can say with strong probability that two functionating kidneys are present. THE NEWER METHODS OF DIAGNOSIS OF RENAL LESIONS. 747 Cryoscopy. Crvoscopy is the determination of tlie molecular concentration of the urine and blood by deter- mining their respective freez- ing-point. The principle of this method is this : The richer a given substance is in regard to molecules, the lower will its freezing-point be below that of distilled water. The best apparatus to use is that of Boeckmann (Fig. 481). Under normal conditions the urine is more concentrated as to molecules than the blood. If comparison between the freezing-point of the blood and of water show that this normal difference is diminished, then the functional capacity of the kidney, i. e., its eliminative power, is diminished. In other words, the ques- tion to be answered is whether one kidney will be sufficient to attend to the necessary elimina- tion after the other has been removed. Normally the human blood has a freezing-point of 0.56° C. lower than the freezing-point of distilled water. If this freez- ing-point of the blood sinks lower than the above-men'- tioned figure, then, according to those who recommend this method, we must conclude that there is retention, consequently pic. 481. -apparatus for ;cRvoscopY:(Fowier). an increase of the molecules in the blood, caused by an insufficient kidney action. A normal freezing- 748 METHODS OF EXAMIXATION. point does not always indicate renal sufficiency. A high freezing-point may be jound when the kidneys have a perfect junctional capacity. If the deviation is more than 0.59° C. it is not advisable, as a rule, to extirpate a kidney. The freezing-point of the urine normally is from — 1.3° to 2.0° below the freezing-point of water; a deviation beyond tliis limit proves the kidney to be unreliable, showing that the molecular concentration of the urine is unusually low. We must be sure that no polyuria exists in order that it may be of value. Extensive investiga- tions have proved that this method is only rehable if the results are positive. Phloridzin Test. The administration of phloridzin leads, as a rule, to temporary glyco- suria. This glycosuria appears fifteen to thirty minutes after the administration of the drug, and disappears usually after three hours. After the urine has begun to run well through the ureteral catheter, twenty minims of a i per cent, phloridzin solution (freshly prepared) are given by intramuscular injection. Delay in the appearance of the sugar, or small quantities of it, is supposed to point to an insufficiency of the kidney. The more renal parenchyma present, the more sugar is excreted, since the phloridzin, by irritating them, causes the withdrawal of sugar from the blood. This method is also reliable only in a positi^'e sense, because researches have proved that sometimes absolutely normal kidneys do not show the sugar reaction. It is of value when combined with ureteral catheterizaion. The employment of tliis method seems to involve a certain risk, as there are a few cases reported in w^hich the administration of phloridzin was followed by hematuria or unusually prolonged glycosuria. All of the previously enumerated methods have in common one serious drawback. They do not furnish us any clue as to whether an existing reduction in the functional capacity of a kidney is not a tem- porary condition due to the toxic substances brought into the circulation from the other, i. e., diseased kidney. Electric Conductivity of Urine. An attempt has been recently made to estimate the functional capa- city of a kidney by determining the fluctuations in the electric resistance of the urine produced by running indigo-carmJn through the kidneys. The principle is this, that first the electric conductivity of the urine is tested; immediately afterward indigo-carmin is injected into the gluteal muscles, and the electric conductivity is again tested half an hour THE NEWER METHODS OF DIAGNOSIS OF RENAL LESIONS. 749 after this administration. It is claimed that diseased kidneys show a decidedly decreased electric resistance after this application, and it is furthermore claimed that any decrease beyond twenty ohms classifies such a kidney as a surgically unreliable one. Healthy kidneys show an increase in electric resistance varying up to ten ohms after the stain appears in the urine. Healthy Iddneys, only temporarily reduced in their functional capacity, which reduction is proved by any of the above mentioned methods, show nevertheless their normal possibihties by an increase of electric resistance after administration of indigo-carmin. INDEX. Abdomen, 231 affections of, acute, 245 pain as early symptom, 256 suppuration as early symptom, 246 condition of, in intussusception, 282 examination of, in enterostenosis, 342 in intestinal strangulation, 280 in volvulus, 280 recti muscles of, suppuration in, 231 tumors of, 285 arising from pelvic viscera of female, 323 auscultation in, 289 due to inflammatory exudates, 320 due to tuberculous peritonitis, 320 having origin in pelvic viscera or bones, 323 history, 285 inflation of stomach or colon in, 289 inspection in, 287 occurring in corresponding locations, 285 _ palpation in, 288 percussion in, 289 results obtained from abdominal ex- amination and its adjuncts, 286 Abdominal aorta and branches, abdominal tumors due to aneurysms of, .321 differential diagnosis, 322 viscera, injuries of, 237 general condition of patient, 238 history and mode of accident, 237 internal hemorrhage in, 244 local signs, 239 symptoms, 240 wall, affections of, 231 congenital conditions of, 235 desmoids of, 233 differential diagnosis, 234 fibroma of, 233 furuncles of, 231 inflammatory affections of, 231 injuries of, 237 lipoma of, 233 pigmented nevi of, 233 jetromuscular suppuration in, 231 suppuration in, 231 tumors of, 233 Abscess, cerebral, otitic, 83 discharging through umliilicus, 236 epidural, 56, 80 extradural, 80 extrasphincteric, 352 formation, leukocytosis in, 721 Abscess in Pott's disease, 688 intrasphincteric, 352 left subphrenic in ulcer of stomach, 334 multiple, of omentum, 255 of brain, 57, 82 acute traumatic, 58 and tumor of brain, differentiation, 80 chronic traumatic, 59 irritation and paralytic symptoms, 83 optic neuritis in, 83 symptoms of, focal, 83 general, 82 of cerebellum, symptoms, 83 of superior rectal space, 352 perisinuous, 80 peritonsillar, 190 prevesical, 232 pulmonary, 213 single, 248 subphrenic, 253 differential diagnosis, 254 temporo-sphenoidal, 83 tropical, 248 differential diagnosis, 248 Acetabulum, fractures of, 497 Achondroplasia, 591 Acid intoxication, hepatic, postoperative, 703 Acromegaly, 592 tumor of pituitary body causing, 79 Actinomycosis, ileocecal, inflammatory tu- mors of intestine from, 307 of face, 97 of jaws, 120 of lungs, 216 of neck, 161 of pleura, 216 of thoracic wall, 202 Adenocarcinoma of sweat or sebaceous glands of extremities, 557 Adenocystoma, benign, of testicle, 399 Adenoma of sweat and sebaceous glands of extremities, 556 of face, 99 thyroid, 186 Adhesions, perigastric, in ulcer of stomach, 335 Adynamic ileus, 2S3 differential diagnosis, 283 Air embolism in injuries of veins of neck, . ^54 . in tissues in fracture of Ijase of skull, 27 Air-passages, foreign bodies in, 156, 220 Albuminuria after fracture of base of skull, 34 751 752 INDEX. Alimentary canal, injuries of, free fluid in peritoneal cavity in, 241 obliteration of liver dullness in, 241 symptoms, 240 tympanites in, 241 vomiting in, 240 Anemia, pernicious, examination of blood in, 728 Aneur3-sm, arteriovenous, of scalp, 69 cirsoid, of extremities, 558 of face, 99 of scalp, 68 false, 431 non-traumatic, of larger vessels of extremi- ties, 559 of abdominal aorta and branches, ab- dominal tumors due to, 321 differential diagnosis, 322 of extremities, 558 of subclavian artery, 153 thoracic, 207 traumatic, 431 of face, 99 of neck, 152 of scalp, 69 Angina Ludovici, 124 sclerotica abdominis, 276 Angioma of face, 98 of muscles of extremities, 572 of salivary glands, 142 of scalp, 68 cavernous, 68 Angle, carrjdng, 474 Ankle-joint, diseases of, 644 dislocations at, 516 in lateral direction, 517 in sagittal section, 516 or near, 516 injuries in vicinity of, 513 tuberculosis of, 645 differential diagnosis, 645 Ankylosis of temporo-maxillary joint, 122 Anthrax complicating wounds, 543 edema complicating wounds, 543 Anuria in renal calculus, 370 Anus, atresia of, 346 fissure of, 354 fistula of, 353 pruritus of, 349 Aorta, abdominal, and branches, abdom- inal tumors due to aneurysms of, 321 differential diagnosis, 322 Aphasia, motor, 47 sensory, 48 visual, 48 Apoplectiform attacks in brain tumors, 76 Apoplexy, late traumatic, 53 Appendicitis, 256 chronic, 341 differential diagnosis, 260 leukocytosis in, 259, 721 in differentiating, 722 pain in, 256 pulse in, 258 temperature in, 259 Appendicitis, tenderness and muscular rigidity in, 257 tumor in, 260 vomiting in, 257 Appendix, vermiform, hernia of, in inguinal hernia, 409 Armor-like cancer, 230 Arteries, injuries of, 429 of extremities, diseases of, 557 of neck, injuries, 152 Arteriovenous aneurysm of scalp, 69 Arteritis of extremities, 557 Artery, carotid, injury of, 152 middle meningeal, hemorrhage from, 48, subclavian, aneurj^sm of, 153 injury of, 152 vertebral, injur}' of, 152 Arthritis, 602 acute, of extremities, 579 traumatic, 604 chronic, 611 of temporo-maxillary joint, 122 deformans, 615 differential diagnosis, 617 general progressive form, 616 Heberden's nodes in, 615 in children and young individuals, 617 monarticular form, 616 of spine, 691 polyarticular form, 616 vertebral form, 616 due to syringomyelia, 624 due to tabes, 622 following infectious diseases, 608 gonorrheal, 609. See also Gonorrheal arthritis. gouty, 618 acute, 618 atypical or irregular form, 619 chronic, 618 neurogenica, 622 neuropathic, 621 pneumococcus, 608 primary acute, of temporo-maxillary joint, 122 secondary acute, 606 by extension, 610 of temporo-maxillary joint, 122 to pus foci elsewhere, 607 syphilitic, 619 acquired, 619 chronic, 619 hereditary, 620 secondary, 619 tertiary, 619 tabetica, 622 traumatic, 450 diagnosis shortly after injury, 452 free bodies in joints in, 455 locking of joint in, 455 rupture of ligaments in, 453 subluxation of cartilages in, 453 tvphoidal, 608 urica, 618 Arthropathie tabetic[ue, 622 INDEX. 753^ Ascites, 318 Aseptic fever, postoperative, 700 Asphyxia, traumatic, 196 Astragalus, dislocation of, 518 fractures of, 520 Atresia ani, 346 et recti, 346 recti, 346 Atrophy, syphilitic, of tongue, 133 Auditory nerve, injury, in fracture of base of skull, 30 Auscultation in empyema, 210 in tumors of abdomen, 289 Back, furuncles on, 201 ulcerations on, in tertiary syphilis, 201 Bacterial infections, effect on opsonic index, 719 _ Balanitis, 385 Barlow's disease, 591 Bile-duct, common, gallstones in, 337, 340 Bile-passages, infection of, leukocytosis in, 722 Bladder, 371 abnormal communication of, cystoscopy in, 744 calculus of, 375 cystoscopy in, 741 congenital malformations, 371 distended, 323 ectopia of, 371 edema of, cystoscopy in, 740 examination of, in renal calculus, 370 exstrophy of, 371 hemorrhoids of, cystoscopy in, 746 hernia of, in inguinal hernia, 407 inflammation of, 372. See also Cystitis. injuries of, symptoms, 243 lesions of, 361 clinical picture, 361 examination of urine in, 361 objective examination in, 362 leukoplakia of, cystoscopy in, 744 parasites of, cystoscopy in, 743 rupture of, in fractures of pelvis, 491 syphilis of, cystoscopy in, 744 tuberculosis of, 374 cystoscopy in, 739 tuberculous catarrh of, cystoscopy in, 739 tumors of, 376 cystoscopy in, 742 ulcers of, cystoscopy in, 739 wounds of, 372 Blastomycotic disease of face, 95 ulcers of extremities, 546 Blood, cryoscopy of, 747 escape of, from ear, nose, and mouth in fracture of base of skull, 27 examination of, 715 in leukemia, 728 in pernicious anemia, 728 in pyemia complicating wounds, 540 in septicemia complicating wounds, 537 Blood-counting apparatus, Thoma-Zeiss, 716 Blood-cysts of neck, 177 Blood-pressure in acute peritonitis, 731 in collapse, 730 in hemorrhage, 730 in injuries of head, 51, 730 in shock, 730 in surgical accidents and diseases, 730 cases, 729 operations, 730 increased, in brain tumors, 75 Blood-vessels, injuries of, 429 in dislocations, 456 in fractures, 443 of base of skull, 32 subcutaneous, 198 Bones, contusions of, 438 cranial, contusions of, 61 injuries of, 422 general considerations upon, 438 of extremities, benign tumors of, 594 carcinoma of, 601 cysts of, 594 diseases of, 575 acute,_575, 577 chronic, 575, 582 enchondroma of, 596 endothelioma of, 601 exostoses of, 595 injuries of, 438 myeloma of, 601 perithelioma of, 594, 601 sarcoma of, 597. See also Sarcoma of hones 0} extremities. syphilis of, 584, 585 acquired, 586 tuberculosis of, 582 tumors of, 593 Bow-legs, 654 Brachial plexus, injuries of, 155, 437 Brain, abscess of, 57, 82. See also Abscess of brain. areas, localization, 44 compression of, 36 first stage, 37 fourth stage, 39 from infection of meninges or brain, or tumors of brain, 37 from intracranial hemorrhage, 36 from splinters of depressed fracture, 36 second stage, 37 stage of advanced compression, 38 of compensation, 37 of incipient or mild compression, 37 of paralysis, 39 third stage, 38 concussion of, 35 stage of depression, 35 of irritation, 36 contusion of, 42 diseases of, 73 injuries of, 17 differential diagnosis, 54 in fracture of skull, 34 suppuration following, 55 laceration of, 42 motor region, tumors of, 76 tumors of, 75 754 INDEX. Brain, tumors of, apoplectiform attacks in, 76 choked disc in, 75 compression from, 37 general convulsions in, 76 headache in, 75 increased blood-pressure in, 75 mental symptoms in, 75 optic neuritis in, 75 slow pulse in, 75 symptoms, focal, 76 general, 75 tenderness of skull in, 76 vertigo in, 76 vomiting in, 75 venous sinuses of, hemorrhage from, 49, 5.3 vs^hite matter of, lesions, 47 Branchial cyst, 174 fistula, 147 Breast, caking of, 222 carcinoma of, 228. See also Carcinoma of breast. diffuse fibroadenoma of, 224 fibroma of, 223 diseases of, 221 fibroadenoma of, 227 hypertrophy of, 227 inflammatory processes of, 221 sarcoma of, 228 tuberculosis of, 225 tumors of, 227 benign, 227- differential diagnosis, 230 malignant, 228 Brenner's ureter-cystoscope, 737 Bronchi, foreign bodies in, 156 Bronchiectasis, 213 Brown-Sequard paralysis, 666 Bulla, formation of, in fractures, 442 Bursa, injuries of, 428 of extremities, diseases of, 566 thyrohyoid, 177 Bursitis, acute, of extremities, 566 chronic, of extremities, 566 syphilitic, of extremities, 567 tuberculous, of extremities, 567 Cachexia in malignant tumors of kidney, 317 Caking of breast, 222 Calculus in bladder, cystoscopy in, 741 renal, 365 anuria in, 370 disturbances in micturition in, 369 examination of bladder in, 370 of ureters in, 370 hematuria in, 368 pain in, 367 radiographic examination in, 369 results of palpation in, 367 urinary changes in, 367 salivary, 125, 140 vesical, 375 Callus formation, delayed, in fractures, 445 Caput obstipum, 150 Carbuncle of neck, 160 Carcinoma, armor-like, 230 en cuirasse, 230 leukocytosis in, 725 of bones of extremities, 601 of breast, 228 age in, 228 complications, 230 condition of nipple and regional lymph-nodes, 229 edema of hand in, 230 location and growth, 229 mobility, consistency, and form, 229 paraplegia dolorosa in, 230 of duodenum, 308 of face, 100 of floor of mouth, 126 of intestine, 308 condition of bowel movements in, 309 differential diagnosis, 309 symptoms of stenosis in, 308 tumor in, 309 of jaws, 115 of larynx, 191 of lips, 108 of liver, 296 of neck, 181 primary, 181 secondary, 181 of parotid gland, 145 of rectum, 359 of scalp, 69 of stomach, 335 hemorrhage in, 335 pain in, 335 tumor in, 336 vomiting in, 335 of tongue, 134 differential diagnosis, 135 Carotid artery, injury of, 152 internal, intracranial portion, injuries, hemorrhage from, 50 body, sarcoma of neck arising from, 180 sheath, sarcoma of neck arising from, 180 space, suppuration in, 159 Carpal bones, dislocations of, 483 fractures of, 483 Carpo-metacarpal dislocations, 484 Carrying angle, 474 Cartilages, costal, fractures of, 194 subluxation of, in traumatic arthritis, 453 Catarrh, tuberculous, of bladder, cystoscopy in> 739 Catheterization, ureteral, 732 in tuberculosis of kidney, 365 Cauda equina, lesions of, 676 Cellulitis, emphysematous, complicating wounds, 534 of finger or hand, complicating wounds, 531 Cephalhematoma, 18 Cephalhydrocele, traumatic, 19 Cephalic tetanus, 541 Cerebellum, abscess of, symptoms, 83 lesions of, 48 tumors of, 77 INDEX. 755 Cerebral abscess, otitic, 83 localization, 44 sinus, thrombosis of, 84 Cerebrospinal fluid, cytodiagnosis of, 731 escape of, in fracture of base of skull, 28 meningitis, cytodiagnosis in, 731 Cervical rib, 148 Chancre of lip, 105 of tongue, 130 Charcot knee-joints, 620 Cheeks, tumors of inside of, 127 Chest, 193. See also Thorax. Choked disc in brain tumors, 75 Cholecystitis, acute, 246 differential diagnosis, 247 phlegmonous, 247 Chondrodystrophia foetalis, 591 Chondroma of jaws, 113 of neck, 178 Chondrosarcoma of parotid gland, 144 Chromocystoscopy, 746 Circulatory complications, postoperative, 710 Circumflex nerve, injuries of, 435 Cirsoid aneurysm of extremities, 558 of face, 99 of scalp, 68 Claudication, intermittent, 551 Clavicle, dislocations of, 464 at acromioclavicular joint, 464 of sternal end, 464 fractures of, 462 Claw-hand, 436 Club-foot, 656 Club-hand, 661 Coeliac parotitis, 141, 713 Colic, gallstone, 264. See also Gallstone colic. in enterostenosis, 342 renal, 270 symptoms of, 270 Collapse, blood-pressure in, 730 postoperative, 699 CoUes' fracture, 482 Colon, inflation of, in tumors of abdomen, 289 Coma and compression of brain, differen- tiation, 40 Compression of brain, 36. See also Brain, Compression of. Concussion of brain, 35 stage of depression, 35 of irritation, 36 of spine, 683 Constipation in enterostenosis, 342 in intestinal obstruction, 277 strangulation, 280 in volvulus, 280 Contraction, Dupuytren's, 573 Contracture, ischemic muscular, of ex- tremities, 571 Contused wounds of scalp, 18 in infants and young children, 18 in older children and adults, 20 Contusions, cerebral, 42 of bones, 438 Contusions of cranial bones, 61 of hip, 498 of muscles, 424 of urethra, 380 simple, effect on skin, 423 Convolutions, ascending frontal and pari- etal, lesions of, 44 general, in brain tumors, 76 Corset liver, 291 differential diagnosis, 292 Costal cartilages, fractures of, 194 Coxa vara, 648 attitude of limb, 650 differential diagnosis, 651 gait and pain, 651 history, 650 limitation of motion, 650 shortening, 650 symptoms, 650 traumatica, 499 jc-ray examination, 651 Coxitis, 631 tuberculous, 632. See also Tuberculosis of hip-joint. Cranial bones, contusions of, 61 Craniotabes, 70 Crepitus in fractures, 447 Crisis, Dietl's, 271, 312 differential diagnosis, 271 visceral, 274 Cryoscopy, 747 apparatus for, 747 Curvature, lateral, of spine, 690 Cutaneous tissue, infection of, complicating wounds, 531 Cut-throat, 156 Cyanosis in penetrating injuries of thorax, 200 Cystadenoma of jaws, no Cystic disease of liver, 295 duct, gallstones in, 340 . goiter, 177 lymphangioma, congenital, of neck, 176 mastitis, chronic, 223 tumors behind rectum, 695 of neck, 174 ulcers, cystoscopy in, 739 Cystitis, 372 acute, 372 general symptoms, 373 painful and increased frequency of urination in, 372 sensation of weight and tenderness in, 373. urine in, 373 chronic, 373 cystoscopy in, 738 differential diagnosis, 374 diphtheritic, 373 nodular and ulcerative tuberculous, cys- toscopy in, 739 tuberculous parenchymatous, cystoscopy in, 739 Cystoscopes, Nitze's, 737 Cystoscopic examination in tuberculosis of kidney, 365 756 INDEX. Cystoscopy, 736 in abnormal communication of bladder, 744 in calculi in bladder, 741 in cystitic ulcers, 739 in cystitis, 738 in edema of bladder, 740 in hemorrhoids of bladder, 746 in hypertrophy of prostate, 740 in leukoplakia of bladder, 744 in nodular and \ilcerative tuberculous cystitis, 739 in parasites of bladder, 743 in patent urachus, 744 in syphUis of bladder wall, 744 in tuberculosis of bladder, 739 in tuberculous catarrh of bladder, 739 parenchymatous cystitis, 739 in tumors of bladder wall, 742 in ulcers of bladder, 739 Cysts, blood, of neck, 177 branchial, 174 dentigerous, of jaws, 108 dermoid, of extremities, 556 of face, 99 of floor of mouth, 126 of neck, 178 of scalp, 67 hydatid, in muscles of extremities, 572 of liver, 294 differential diagnosis, 294 suppurating, 254 of neck, 177 ' of spleen, 306 lymph, of extremities, 564 of accessory thyroids and parathyroids, 177 of bones of extremities, 594 of mesentery, 310 of pancreas, 301 differential diagnosis, 302 of salivary ducts, 142 glands, 142 retention-, of salivary glands, 141 sebaceous, of extremities, 556 of face, 99 of neck, 178 thyroglossal, 126, 176 unilocular, of neck, 177 Cytodiagnosis, 731 of cerebrospinal fluid, 731 meningitis, 731 of pleural fluids, 732 of tuberculous meningitis, 731 Deafness, word-, 48 Decubital ulcers of extremities, 548 of tongue, 128 Defence musculaire, 240 Deformities caused by anterior poliomyeli- tis, 654 congenital, of hands, 661 in dislocations, 459 in fractures, 447 in Pott's disease, 687 of extremities, 646 Delirium, traumatic, 528, 529 in fractures, 444 tremens, 528, 529 in fractures, 444 Dental ulcers, 128 Dentigerous cysts of jaws, 108 Dermoid cysts of extremities, 556 of face, 99 of floor of mouth, 126 of neck, 178 of scalp, 67 sequestration, sacrococcygeal, 695 Descent, imperfect, of testicle, 388 complications, 388 hernia and hydrocele in connection with, 391 inflammation in, 389 tumor formation in, 389 Desmoids of abdomen, 233 differential diagnosis, 234 of muscles of extremities, 572 Diabetic complications, postoperative, 712 gangrene of extremities, 551 Diaphragm, penetrating wounds of, 201 subcutaneous injuries of, 197 Diaphragmatic hernia, 421 Dietl's crisis, 271, 312 differential diagnosis, 271 Digestion, disturbances of, leukocytosis in, 723 Digits, supernumerary, 661 Dilatation, idiopathic, of esophagus, 330 of stomach, 331, 332 from acquired stenosis of pylorus, 332 from congenital stenosis of pylorus, 331 postoperative, 706 Diphtheritic cystitis, 373 Dislocations at ankle-joint, 516 in lateral direction, 517 in sagittal section, 516 carpo-metacarpal, 484 change in length of limb in, 461 congenital, of hip, 646 differential diagnosis, 647 of extremities, 646 of knee, 648 of patella, 648 of shoulder, 648 deformity in, 459 diagnosis in general, 458 disturbance of function of limb in, 461 general considerations on, 456 habitual, 456 injury of blood-vessels in, 456 of nerves in, 457 ■ near ankle, 516 objective signs of, 459 of astragalus, 518 of carpal bones, 483 of clavicle, 464 at acromioclavicular joint, 464 of sternal end, 464 of hip, 496 of jaw, 90 of knee, 506 backward, 506 INDEX. 757 Dislocations of knee, forward, 506 of metacarpal bones, 486 of metatarsal bones, 523 of patella, 505 of phalanges, 486 of radius, 478 and ulna, 477 backward, 478 of shoulder-joint, 470 backward forms, 472 subspinous forms, 472 of shoulder region, 461 of spine, 679 pathology, 664 of tendons, 427 of toes, 524 of ulna and radius, 477 backward, 478 of vertebrae, 679 pathology, 664 of wrist, 484 pathologic, 456 recurrent, 456 special, 461 subacromial, 472 subastragaloid, 518 subclavicular, 472 subcoracoid, objective signs, 471 subglenoid, symptoms of, 472 tibiotarsal, 516 ^-ray examination in, 461 Displacement, congenital, of kidney, 311 Distended bladder, 323 Diverticula of esophagus, 177, 329 of pharynx, 177 Drug eruptions, postoperative, 712 Drugs, poisoning from, postoperative, 712 Dullness in flanks and right iliac region in perforating ulcers of stomach and duo- denum, 267 liver, obliteration of, in perforating ulcers of stomach and duodenum, 266 Duodenal ulcer, 332. See also Ulcer of stomach. Duodenum, cancer of, 308 ulcer of, 332. See also Ulcer of stomach. perforating, 266. See also Ulcer, per- forating, of duodenum. Dupuytren's contraction, 573 Dyspeptic symptoms in ulcer of stomach, 333 Dyspnea in penetrating injuries of thorax, 200 Ear, escape of blood from, in fracture of base of skull, 27 middle, suppuration from, intracranial complications, 80 Echinococcus cysts. See Hydatid cysts. Ectopia testis, 388 vesicae, 371 Edema, anthrax, complicating wounds, 543 malignant, complicating wounds, 534 of bladder, cystoscopy in, 740 of glottis, 190 of hand in cancer of breast, 230 Edema, pulmonary, in fractures, 444 Elbow, miner's, 567 pulled, 479 sprains of, 473 Elbow-joint, injuries in vicinity of, 478 tuberculosis of, 628 Electric conductivity of urine, 748 Elephantiasis, 554 Eleventh nerve, injury, in fracture of base of skull, 31 Embolic gangrene of extremities, 552 Embolism, air, in injuries of veins of neck, fat, in fractures, 443 in fractures, 442 of mesenteric vessels, 272 differential diagnosis, 273 postoperative, 710 pulmonary, postoperative, 702 Emphysematous cellulitis complicating wounds, 534 Empyema, 208 auscultation in, 210 causes, 208 clinical course, 209 differential diagnosis, 210 exploratory puncture in, 210 history, 209 in penetrating injuries of thorax, 200 inspection in, 209 metapneumonic, 208 of joints, tuberculous, 612 palpation in, 209 percussion in, 209 physical examination in, 209 tuberculous, 208 Enchondroma of bones of extremities, 596 of ribs, 207 Endothelioma of bones of extremities, 601 Enlargement of cervical lymph-nodes, 163. See also Lymph-nodes of neck, enlarge- ment. of kidney, diseases accompanied by, 313 in renal tuberculosis, 365 of lips, 104 of prostate, 377 differential diagnosis, 378 of spleen, 305 Enterocele, acute partial, 404 Enterostenosis, 341 colic in, 342 condition of feces in, 342 constipation in, 342 examination of abdomen in, 342 history in, 342 peristalsis in, 342 tympanites in, 342 Epidermal infection complicating wounds, 531 Epididymis, tumors of, 399 Epididymitis, gonorrheal, 392 Epidural abscess, 56, 80 Epilepsy, traumatic, 62 Epiphyseal separation of femur in children, 500 Epiphysitis of extremities, 580 758 INDEX. Epispadias, 379 Epithelioma of extremities, 557 of face, loi of lips, 107 of penis, 386 Epulis, 112 Eruptions, drug, postoperative, 712 postoperative, 711 Erysipelas complicating wounds, 535 facial, 92 leukocj'tosis in, 721 of scalp, 66 Er\'sipeloid complicating wounds, 536 Esophagus, diseases of, 324 diverticulum of, 177, 329 foreign bodies in, 330 methods of examination, 331 idiopathic dilatation of, 330 stricture of, 324. See also Stricture of esophagus. subcutaneous injuries of, 198 Examination, methods of, 715 Exophthalmic goiter, 189 Moebius' symptom of, 189 Stell wag's symptom of, 189 von Graefe's symptom of, 189 Exostoses of bones of extremities, 595 Exploratorv' puncture in empyema, 210 Exstrophy of bladder, 371 Extradural abscess, 80 Extrasphincteric abscess, 352 Extra-uterine pregnancy, rupture of, 284 Extremities, 422 diseases of, 544 of skin, 554 and subcutaneous tissues, 544 lower, infection in, complicating wounds, 534 tumors of skin and subcutaneous tissue, 555 Exudates, inflammator}', abdominal tumors due to, 320 Face, actinomycosis of, 97 angioma of, 98 benign tumors of, 98 blastomycotic disease of, 95 bones of, fractures, 87 injuries, 87 carcinoma of, 100 cirsoid aneurysms of, 99 dermoid cysts of, 99 epithelioma of, 10 1 erv'sipelas of, 92 fibroma molluscum of, 99 furuncles of, 94 injuries and diseases of, 86 lipoma of, 99 lupus of, 95 malignant tumors of, 100 neoplasms of, 98 sarcoma of, loi sebaceous cysts of, 99 glands, adenoma of, 99 soft parts, diseases of, 92 infections of, 92 Face, soft parts, injuries of, 86 sweat glands, adenoma of, 99 S}'phLlis of, 96 traumatic aneur\'sms of, 99 Facial ner\"e, injur}' of, 139 in fracture of base of skull, 28 Facies in perforating ulcers of stomach and duodenum, 267 False aneur}-sm, 431 Fasciae of extremities, diseases of, 573 Fat embolism in fractiires, 443 Feces, condition of, in enterostenosis, 342 examination of, 732 Feet, foreign bodies in, 661 Felon, 532 Femoral hernia, 414 differential diagnosis, 415 Femur, epiphyseal separation, in children, 500 fractures of, 500 of head, 497 of lower end, 503 of neck, 493 in children, 499 of shaft, 501 Ferment fever, postoperative, 700 Fetal rickets, 591 Fever in gallstone colic, 264 in intussusception, 282 Fibroadenoma, diffuse, of breast, 224 of breast, 227 Fibroma, diffuse, of breast, 223 molluscum of face, 99 of abdomen, 233 of jaws. III of neck, 179 of salivar}- glands, 142 of scalp, 68 of thorax, 206 Fibula, fractures of lower end, 514 of upper end, 509 isolated fractures of upper and middle thirds of shaft, 512 Finger, cellulitis of, complicating wounds, Finger-joints, diseases of, 629 Fingers, webbed, 661 Fissure of anus, 354 Fistula, branchial, 147 in ano, 353 salivar}', 139 thyroglossal, 147 Flat-foot, 657 Floating kidney, 312 differential diagnosis, 313 . liver, 293 differential diagnosis, 293 spleen, 304 Foreign bodies in air passages, 156, 220 in bronchi, 156 in esophagus, 330 methods of examination, 331 in feet, 661 in hands, 661 in rectum, 348 in trachea, 156 INDEX. 759 Foreign bodies, intestinal obstruction from, 282 Fossa, individual, of base of skull, fracture, 32 middle, of skull, tumors of, 78 Fourth nerve, injury, in fracture of base of skull, 30 Fractures, 438 abnormal mobility of bone in, 447 associated with fragilitas ossium, 441 with general diseases, 441 with idiopathic friability of bone, 441 ■with local lesions of bone, 441 with osteoporosis, 441 closed, 439 CoUes', 482 complete, 438, 439 complicated, 439 complications of, 442 compound, 439 crepitus in, 447 deformity in, 447 delayed callus formation in, 445 union in, 445 delirium tremens in, 444 diagnosis in general, 446 displacement of fragments, 440 embolism in, 442 fat embolism in, 443 faulty union in, 446 fibrous union in, 445 formation of bullae in, 442 greenstick, of radius and ulna, 480 gunshot, 439 healing of, 442 history in, 446 in sarcoma of bones of extremities, 600 incomplete, 438, 439 injury to blood-vessels in, 443 to nerves in, 443 intercondyloid, of lower end of humerus, .474 isolated, of upper and middle thirds of shaft of fibula, 512 longitudinal, 439 loss of function of limb in, 448 mal-union in, 446 number of fragments, 440 objective signs of, 447 oblique, 439 of acetabulum, 497 of astragalus, 520 of bones of face, 87 of carpal bones, 483 of clavicle, 462 of costal cartilages, 194 of femur, 500 of great trochanter, 498 of head and neck of radius, 477 of femur, 497 of hyoid bone, 155 of inferior maxilla, 89 of larynx, 155 of lower end of fibula, 514 of humerus, 473 Fractures of lower end of humerus, epi- physeal separation, 475 of external epicondyle and exter- nal condyle, 476 of internal epicondyle or internal condyle, 476 of radius, 482 of tibia, 514 of lower jaw, 89 of lumbar vertebrae, 678 of malar bone, 88 of metacarpal bones, 486 of metatarsal bones, 522 of nasal bones, 87 of neck of femur, 493, 503 in children, 499 of OS calcis, 521 of patella, 505 of pelvis, 488 abnormal mobility in, 489 pain in, 489 rupture of bladder in, 491 of urethra in, 490 of phalanges, 486 of toes, 522 of ribs, 193 signs due to fracture alone, 193 due to injury of intrathoracic viscera, 194 of scapula, 465 of shaft of femur, 501 of humerus, 472 of radius, 479 of tibia, 510 of ulna, 479 of shoulder region, 461 of skull, 22 at later period, 26 • depressed, 24 compression of brain from splinters, 36 of vertex, 25 examination of vertex, 23 where no scalp wound is present, 23 where wound of scalp exists, 25 fissured, 25 history of mode of injury, 22 intracranial symptoms, 34 of base, 27 albuminuria after, 34 escape of blood from ear, nose, and mouth, 27 of cerebrospinal fluid, 28 glycosuria after, 34 hemorrhage or presence of air in tissues, 27 injury of auditory nerve, 30 of facial nerve, 28 of hypoglossal nerve, 31 of nerves, 28 of ninth, tenth, and eleventh nerves, 31 of olfactory nerve, 30 of optic nerve, 30 6o INDEX. Fractures of skull, of base, injury of third, fourth, and sixth nerves, 30 of trigeminal nerve, 31 of twelfth nerve, 31 of vessels, 32 of individual fossae, 32 of both tables, 26 of external table, 25 of internal table, 26 punctured, 25 of spine, 676 from third cervical to second dorsal vertebra, 677 to twelfth dorsal vertebrae, 678 of atlas and axis, 676 of upper two cervical vertebrae, 676 pathology, 664 of sternum, 194 of superior maxilla, 88 of surgical neck of humerus, 469 of tarsal bones, 519 of trachea, 155 of upper end of fibula, 509 of humerus, 466 epiphyseal separation, 468 of anatomic neck, 467 of radius, 477 of tibia, 506 of ulna, 477 of upper jaw, 88 open, 439 _ osteomyelitis in, 443 pain in, 448 pathologic, 439, 441 pertrochanteric, of Kocher, 498 pneumonia in, 444 Pott's, 514 pseudarthrosis in, 445 pulmonary edema in, 444 seat of, 440 septic complications in, 443 simple, 439 special, 461 spiral, 439 spontaneous, 441 subjective signs of, 448 subperiosteal, 441 supracondyloid, of humerus, 474 T, of lower end of humerus, 474 thrombosis in, 442 transverse, 439 traumatic delirium in, 444 union with deformity in, 446 vicious union in, 446 a:-ray examination in, 449 Y, of lower end of humerus, 474 Fragilitas ossium, fracture associated with, - 441 Free bodies in joints in traumatic arthritis, 455 Frontal convolution, ascending, lesions of, 44 lobe, lesions of, 47 tumors of, 76 Frost-bite, gangrene of extremities from, 552 Furuncles of abdomen, 231 Furuncles of back, 201 of face, 94 of neck, 160 Gallbladder, gallstones in, 339 hydrops of, 297 infection of, leukocytosis in, 722 malignant disease of, 298 region, palpation of, in gallstones, 339 ttunors of, 297 differential diagnosis, 298 Gallstone colic, 264 differential diagnosis, 264 fever in, 264 jaundice in, 264 muscular rigidity in, 264 pain and tenderness in, 264 vomiting in, 264 Gallstones, 337 diagnosis in interval, 338 of location, if arrested temporarily or permanently, 339 differential diagnosis, 337 history, 338 in common duct, 337, 340 in cystic duct, 340 in gallbladder, 339 leukocytosis in, 724 palpation of gallbladder region in, 339 physical examination in, 339 Ganglion of extremities, 570 Gangrene of extremities, 548 diabetic, 551 dry, 549 embolic, 552 from frost-bite, 552 from injury to arteries or veins of limb, 552 from Raynaud's disease, 553 in infectious diseases, 552 moist, 549 pre-senile, 551 senile, 551 pulmonary, 213 Gangrenous stomatitis, 123 Gastro-intestinal tract, diseases of, leuko- cytosis in, 723 Genito-urinary tract, lower portion of, localization of pus in, 381 instrumental examination for, 383 two-glass test for, 381 urethroscop}- for, 384 Genu valgum, 653 varum, 654 Gibbus in Pott's disease, 688 Glanders complicating wounds, 543 Glossitis, acute, 128, 129 chronic, 129 Glottis, edema of, 190 Glycosuria after fracture of base of skull, 34 Goiter, 179, 185 cystic, 177 exophthalmic, 189. See also Exophthal- mic goiter. fibrous, 186 INDEX. 761 Goiter, lingual, 137 malignant, 187 non-malignant, 185 retrosternal, 187 simple parenchymatous, 185 vascular, 186 Gonitis, tuberculous, 641. See also Tuber- culosis of knee-joint. Gonorrheal arthritis, 609 phlegmonous, 609 purulent, 609 serofibrinous, 609 articular hydrops, 609 epididymitis, 392 orchitis, 392 peritonitis, acute, 250 Gouty arthritis, 618 acute, 618 atypical or irregular form, 619 chronic, 618 Graefe's symptom in exophthalmic goiter, 189 Granulation-tissue tumors of jaws, iii Granuloma of jaws, in Greenstick fractures of radius and ulna, 480 Gumma of lips, 106 Gummatous osteomyelitis of extremities, 587 periostitis of extremities, 587 Gunshot fractures, 439 wounds of spine, 684 Habitual dislocation, 456 Hallux valgus, 661 Hands, cellulitis of, complicating wounds, congenital deformities, 661 edema of, in cancer of breast, 230 foreign bodies in, 661 Harelip, 103 Head, affections, 17 injuries of, blood-pressure in, 730 tetanus, 541 Headache in brain tumors, 75 in purulent leptomeningitis, 81 Heart, diseases of, postoperative, 702 penetrating injuries of, 200 subcutaneous injuries of, 198 Heberden'-S nodes in arthritis deformans, Hemangioma of extremities, 556 of neck, 176 cavernous, 176 of tongue, 133 Hemangiosarcoma of extremities, 557 Hematcmesis, postoperative, 706 Hematomyelia, 681 Hematorachis, 681 Hematuria in malignant tumors of kidney, 315 in renal calculus, 368 Hemophilia, 433 Hemophiliac joints, 624 Hemorrhage, 525 blood-pressure in, 730 characteristic signs of, 525 Hemorrhage, compression of brain from, 36 concealed, postoperative, 697 external, postoperative, 697 from injuries of intracranial portion of internal carotid and vertebral arteries, from middle meningeal artery, 48 from smaller arteries of pia arachnoid, 49 from venous sinuses of brain, 49, 53 in cancer of stomach, 335 in fracture of base of skull, 27 in scalp, location, 18 in ulcer of stomach, 333 intermeningeal, 49, 52 internal, early signs of, 284 in injuries of abdominal viscera, 244 postoperative, 697 intracranial, 48 middle meningeal, 48, 50 postoperative, 696 subdural, 52 Hemorrhoids, 355 of bladder, cystoscopy in, 746 Hemothorax in penetrating injuries of thorax, 199 Hepatoptosis, 293 Hernia, 401 cerebri, 62 diaphragmatic, 421 femoral, 414 differential diagnosis, 415 in connection with imperfect descent of testicle, 391 incarcerated, 402 inflamed, 402 inguinal, 404 differential diagnosis, 409 direct, 406 hernia of bladder in, 407 of ovary in, 409 of vermiform appendix in, 409 indirect, 405 interstitial, 407 oblique, 405 straight, 406 unusual contents of, 407 Littre's, 404 lumbar, 421 obstructed, 402 obturator, 421 of bladder in inguinal hernia, 407 of muscles, 427 of ovary in inguinal hernia, 409 of vermiform appendix in inguinal hernia, 409 pulmonary, 207 rarer forms of, 421 sciatic, 421 strangulated, 403 umbilical, 417 congenital, 417 in adults, 418 infantile, 417 ventral, 420 Herpes of lips, 104 76: IXDEX. Hip, congenital dislocations of, 646 differential diagnosis, 647 contusion of, 498 dislocation of, 496 injuries of, 492 in children, 498 Hip-joint, diseases of, 631 tuberculosis of, 632. See also Tuhercu- losis 0} hip-joint. Hodgkin's disease, enlargement of cervical lymph-nodes in, 166 Hour-glass stomach in ulcer of stomach, 334 Housemaid's knee, 567 Humerus, fractures of lower end, 473 epiphyseal separation, 475 intercondyloid, 474 of external epicondyle and external condyle, 476 of internal epicondyle or internal condyle, 476 of shaft, 472 of surgical neck, 469 supra condj'loid fracture of, 474 T-fractures, of lower end, 474 upper end, fractures of, 466 epiphyseal separation, 468 of anatomic neck, 467 Y-fractures, of lower end, 474 Hydatid cysts in muscles of extremities, 572 of liver, 294 differential diagnosis, 294 suppurating, 254 of lungs, 216. of neck, 177 of skull, 72 of spleen, 306 Hydrocele in connection with imperfect descent of testicle, 391 Hydrocephalocele, 71 Hydrocephalus, 73 Hydronephrosis, 313 differential diagnosis, 314 Hydrophobia complicating wounds, 542 Hydrophobic tetanus, 541 Hydrops, articular, tuberculous, 611 of gallbladder, 297 of joints, chronic, 614 gonorrheal, 609 intermittent, 605, 614 Hyoid bone, fractures of, 155 Hyperleukocytosis, 720 Hypertrophy of breasts, 227 of prostate, cystoscopy in, 740 Hypoglossal ner^'e, injur}', in fracture of base of skull, 31 Hypospadias, 379 Hysteria, postoperative, 714 Hysterical joints, 626 spine, 692 Icterus, postoperative, 703 Ileocecal actinomycosis, inflammatory tu- mors of intestine from, 307 tuberculosis, inflammatory tumors of intestine from, 307 Ileus, 277 Ileus, adynamic, 283 differential diagnosis, 283 postoperative, 707 Incarcerated hernia, 402 Index, opsonic, 719 abnormal, 719 effect of bacterial infections on, 719 phagocytic, of leukocyte, 718 Infection along tendon-sheaths complicat- ing wounds, 532 between muscles and tendons of forearm and arm complicating wounds, 532 epidermal, complicating wounds, 531 hepatic, 248 in lower extremities complicating wounds, .534 in wounds of upper extremities, 530 intracranial, follov^-ing injury, differen- tial diagnosis, 61 of cutaneous and subcutaneous tissues complicating wounds, 531 of lymph-nodes of scalp, 66 of male reproductive organs, 391 of scalp, 65 postoperative, 700 renal, 251 subungual, complicating wounds, 532 ungual, complicating wounds, 532 Infectious diseases, arthritis following, 608 gangrene of extremities in, 552 leukocytosis in, 720 Inflamed hernia, 402 Inflammation, acute, of lymph-nodes of extremities, 565 of neck, 162 chronic, of Ivmph-nodes of extremities, 566 of bladder, 372. See also Cystitis. of intra-abdominal portion of vas defer- ens, 276 of testicle in imperfect descent, 389 Inflammatory exudates, abdominal tumors due to, 320 processes of rectum and results, 349 Inflation of stomach or colon in diagnosis of tumors of abdomen, 289 Inguinal hernia, 404. See also Hernia, inguinal. Inspection in tuberculous coxitis, 632, 633 in tumors of abdomen, 287 of rectum, 345 Instrumental examination for localization of pus in genito-urinary tract, 383 Intermittent claudication, 551 Intestinal obstruction, 277 acute, 277 chronic, 341. See also Enterostcnosis. constipation in, 277 early signs of, 277 examination of abdomen in, 280 from foreign bodies, 282 history of, 282 from tumors, 282 history of, 282 leukocytosis in, 723 pain in, 278 INDEX. 763 Intestinal obstruction, probable nature and seat of, 279 symptoms of, 277 vomiting in, 278 strangulation, 279 constipation in, 280 history of, 279 nausea in, 280 pain in, 279 shock in, 280 vomiting in, 280 Intestine, carcinoma of, 308 condition of bowel movements in, 309 differential diagnosis, 309 symptoms of stenosis in, 308 tumor in, 309 evacuation of, in intussusception, 282 neoplasms of, 308 tumors of, 307 inflammatory, 307 from ileocecal actinomycosis, 307 from tuberculosis, 307 Intoxication, acid, hepatic postoperative, 703 Intrasphincteric abscess, 352 Intussusception, 281 condition of abdomen in, 282 evacuation of bowels in, 282 fever in, 282 meteorism in, 282 nausea in, 282 pain in, 281 previous history, 281 prostration in, 282 tenesmus in, 282 tumor in, 282 vomiting in, 282 Jaundice in gallstone colic, 264 Jaw, dislocation of, 90 lower, fractures of, 89 upper, fractures of, 88 Jaws, actinomycosis of, 120 acute suppurative osteomyelitis of, 121 carcinoma of, 115 chondroma of, 113 cystadenoma of, no dentigerous cysts of, 108 diseases of, 108 fibroma of, in granulation-tissue tumors of, in granuloma of, in infections of, 117 following compound fractures, 119 from teeth, nS odontoma of, 109 osteoma of, no phosphorus necrosis of, 121 sarcoma of, 113 syphilis of, 120 tuberculosis of, 119 tumors of, 108 benign, 108 malignant, 113 Joints, acute rheumatism of, leukocytosis in, 721 Joints, chronic rheumatism of, 618 diseases of, 601 examination of joint, 603 general condition of patient, 603 history of case, 603 empyema of, tuberculous, 612 free bodies in, in traumatic arthritis, 455 hemophiliac, 624 hydrops of, chronic, 614 gonorrheal, 609 intermittent, 605, 614 tuberculous, 611 hysterical, 626 injuries of, 422 general considerations upon, 450 lipoma of, 626 neuralgic, 626 of extremities, injuries of, 438 rheumatism of, acute, 605 scorbutic, 624 tuberculosis of, 611. See also Tubercu- losis of joints. tumors of, 626 Keloid of extremities, 555 Kidney, calculus in, 365. See also Calcu- lus, renal. colic of, 270 symptoms, 270 congenital displacement of, 311 malformations of, 312 diseases of, newer methods of diagnosis, 732 postoperative, 709 enlargement of, diseases accompanied by; 313 in tuberculosis of kidney, 365 floating, 312 differential diagnosis, 313 in pyemia complicating wounds, 539 in septicemia complicating wounds, 537 infections of, 251 injury of, symptoms, 241 lesions of, 361 clinical picture, 361 examination of urine in, 361 objective examination in, 362 malignant tumors of, 315 cachexia in, 317 hematuria in, 315 metastases in, 317 pain in, 316 tumors in, 316 metastatic suppuration of, 252 movable, 312 differential diagnosis, 313 neoplasms of, 314 differential diagnosis, 318 polycystic, 314 differential diagnosis, 314 tuberculosis of, 363. See also Titiercn- losis of kidney. tumors of, 3 1 1 Knee, dislocations of, 506 backward, 506 forward, 506 764 INDEX. Knee, housemaid's, 567 Knee-joint, Charcot, 620 congenital dislocation of, 648 diseases of, 639 injuries in vicinity of, 504 tuberculosis of, 641. See also Tubercu- losis of knee-joint. Knock-knee, 653 Kocher's pertrochanteric fracture, 498 Laceration of brain, 42 Lachrymal and salivary glands, symmetri- cal disease of, 98 Larynx, carcinoma of, 191 fractures of, 155 papilloma of, 190 Leg, varicose ulcers of, 545 Leptomeningitis, purulent, 56, 81 headache in, 81 optic neuritis in, 81 pulse in, 81 respiration in, 81 Leukemia, examination of blood in, 728 lymphatic, enlargement of cervical lymph- nodes in, 164 Leukocyte-count, differential, 715 value of, 725 in differential diagnosis, 726 Leukocytes, phagocytic index of, 718 Leukocytosis, 720 in abscess formation, 721 in acute articular rheumatism, 721 in appendicitis,. 259, 721 in differentiating, 722 in carcinoma, 725 in diseases of gastro-intestinal tract, 723 of nervous system, 724 of pancreas, 724 of urinary system, 724 in disturbances of digestion, 723 in duodenal ulcer, 723 in erysipelas, 721 in gallstones, 724 in gastric ulcer, 723 in infection of gallbladder and bile-pas- sages, 722 of serous membranes, 723 in infectious diseases, 720 in intestinal obstruction, 723 in malignant disease, 724 in meningitis, 721 in osteomyelitis, 723 in pelvic peritonitis, 722 in pneumonia, 720 in salpingitis, 722 in sarcoma, 725 in scarlet fever, 721 in septicemia, 721 in surgical conditions of liver, 723 ' in syphilis, 728 in tuberculosis, 727 in typhoid fever, 720 pathologic, 720 physiologic, 720 Leukoma, 129 Leukopenia, 720 Leukoplakia, 129 of bladder, cystoscopy in, 744 Ligaments, rupture of, in traumatic arthri- tis, 453 Lingual goiter, 137 tonsil, 138 Lipoma arborescens, 626 at floor of mouth, 126 of abdominal wall, 233 of face, 99 of joints, 626 of neck, 178 of salivary glands, 143 of scalp, 67 of thorax, 206 of tongue, 133 Lips, 104 carcinoma of, 108 chancre of, 105 enlargement of, 104 epithelioma of, 107 gumma of, 106 herpes of, 104 malformations of, 103 ulcerations of, 105 Litigation symptoms, 683 Littre's hernia, 404 Liver, acid intoxication of, postoperative, 703 carcinoma of, 296 corset, 291 differential diagnosis, 292 cystic disease of, 295 diseases of, postoperative, 703 dullness, obliteration of, in injuries of alimentary canal, 241 in perforating ulcers of stomach and duodenum, 266 floating, 293 differential diagnosis, 293 hydatid cysts of, 294 differential diagnosis, 294 infections of, 248 sarcoma of, 296 suppurating echinococcus cysts of, 254 surgical conditions of, leukocytosis in, 723 syphilis of, 296 tumors of, 291 malignant, 296 differential diagnosis, 297 Localization, cerebral, 44 spinal, 666 Locking of joint in traumatic arthritis, 455 Lockjaw, 122, 540. See also Tetanus. Lumbar hernia, 421 puncture, determining point for, 52 method of performing, 53 vertebrae, fractures of, 678 Lungs, abscess of , 213 actinomycosis of, 216 echinococcus of, 216 edema of, in fractures, 444 embolism of, postoperative, 702 gangrene of, 213 hernia of, 207 postoperative complications of, 701 INDEX. 765 Lungs, prolapse of, in penetrating injuries of thorax, 200 subcutaneous injuries of, 196 tumors of, 217 Lupus of face, 95 Luschka's gland, sarcoma of neck arising from, 180 Lymphangioma, congenital cystic, of neck, 176 of extremities, 556 of face, 100 of tongue, 134 Lymphangiosarcoma of extremities, 557 Lymphangitis, acute, of extremities, 563 chronic, of extremities, 564 Lymphatic leukemia, enlargement of cer- vical lymph-nodes in, 164 Lymph-cysts of extremities, 564 Lymph-nodes of extremities, acute inflam- mation of, 565 chronic inflammation of, 566 diseases of, 565 of neck, acute inflammation, 162 affections, 162 enlargement, 163 carcinomatous, 167 in lymphatic leukemia, 164 in lymphosarcoma, 165 in pseudo-leukemia, 166 simple hyperplastic, 172 syphilitic, 168 tuberculous, 169 of scalp, infection, 66 pelvic, neoplasms of, 323 Lymphosarcoma, enlargement of cervical lymph-nodes in, 165 Lymph-vessels of extremities, diseases of, 563 Macrolabia, 104 Main en griffe, 436 Mai perforans pedis, 546 Maladie cystique, 223 Malar bone, fractures of, 88 Malformations, congenital, of bladder, 371 of kidney, 312 of neck, 147 of penis, 379 of rectum, 346 of urethra, 379 in connection with urachus, 236 of lips, 103 of neck, acquired, 147 congenital, 147 Mal-union in fractures, 446 Mastitis, acute puerperal, 221 chronic, 223 cystic, 223 interstitial, 224 neonatorum, 223 traumatic, 223 Mastoid suppuration, intracranial compli- cations of, 80 Maxilla, inferior, fractures of, 89 superior, fractures of, 88 Median nerve, injury of, 437 Mediastinum, affections of, 218 inflammatory processes of, 218 tumors of, 219 Medulla, lesions of, 48 Meningeal artery, hemorrhage from, 48 Meninges, infection, compression of brain from, 37 Meningitis, cerebrospinal, cytodiagnosis in, 731 leukocytosis in, 721 serous, 82 tuberculous, cytodiagnosis in, 731 Meningocele, 71, 662 spuria traumatica, 19 Mental disturbances following cranial in- jury, 64 in pyemia complicating wounds, 539 in septicemia complicating wounds, 537 symptoms in brain tumors, 75 Mesenteric vessels, embolism of, 272 differential diagnosis, 273 thrombosis of, 272 differential diagnosis, 273 Mesentery, cysts of, 310 tumors of, 310 Metacarpal bones, dislocations of, 486 fractures of, 486 Metapneumonic empyema, 208 Metatarsal bones, dislocations of, 523 fractures of, 522 Metatarsalgia, 660 Meteorism in intussusception, 282 Microstomia, 104 Micturition, disturbances in, in renal calcu- lus, 369 painful and increased frequency of, in acute cystitis, 372 Middle ear suppuration, intracranial com- plications of, 80 Mikulicz's disease, 98 Miner's elbow, 567 Mobility, abnormal, in fractures of pelvis, 489 Moebius' symptom of exophthalmic goiter, 189 Moles on extremities, 556 pigmented, of scalp, 68 of thorax, 206 Molluscum fibrosum of face, 99 Morton's disease, 660 Motor aphasia, 47 region of brain, tumors of, 76 Mouth, diseases of, 103, 123 escape of blood from, in fracture of base of skull, 27 floor of, carcinoma of, 126 dermoid cysts at, 126 diagnosis of conditions at, 124 lipoma at, 126 injuries of, 123 syphilis of, 124 Movable kidney, 312 differential diagnosis, 313 Mucous patches on tongue, 131 Mummification of extremities, 549 Mumps, 140 766 INDEX. Muscles and tendons of forearm and arm, infection between, complicating wounds, 532 contusions of, 424 hernia of, 427 injuries of, 424 of extremities, angioma of, 572 desmoids of, 572 diseases of, 570 hydatid cysts in, 572 inflammatory affections, 570 sarcoma of, 572 tumors of, 572 penetrating wounds of, 428 rupture of, 426 Muscular contracture, ischemic, of extrem- ities, 571 paralysis of extremities, 571 rheumatism, acute, of extremities, 570 rigidity in appendicitis, 257 in gallstone colic, 264 in perforating ulcers of stomach and duodenum, 266 Musculospiral nerve, injuries of, 435 Myelocele, 662 Myelocystocele, 662 Myeloma of bones of extremities, 601 Myelomeningocele, 662 Myoma, large, of uterus, 324 Myositis, acute serous, of extremities, 570 suppurative, of extremities, 571 fibrous, of extremities, 571 ossificans of extremities, 571 sclerosing, of extremities, 571 simple chronic, of extremities, 571 syphilitic, of extremities, 571 traumatic ossifying, 425 tuberculous, of extremities, 571 Nasal bones, fractures of, 87 deformity due to syphilis, 98 septum, injuries of, 87 Nausea in intestinal strangulation, 280 in intussusception, 282 in ulcer of stomach, 333 in volvulus, 280 Neck, actinomycosis of, 161 affections of, 147 arteries of, injuries, 152 blood-cysts of, 177 carbuncle of, 160 carcinoma of, 181 primary, 181 secondary, 181 chondroma of, 178 cystic tumors of, 174 dermoid cysts of, 178 echinococcus cysts of, 177 fibroma of, 179 furuncle of, 160 hemangioma of, 176 cavernous, 176 inflammatory processes in, 157 injuries of, 152 lipoma of, 178 lymphangioma of, congenital cystic, 176 Neck, lymph-nodes of, acute inflammation, 162 affections, 162 enlargement, 163. See also Lymph- nodes of neck, enlargement. malformations of, acquired, 147 congenital, 147 nerves of, injuries, 154 osteoma of, 178 previsceral suppuration in, 158 sarcoma of, 179 arising from carotid body, 180 sheath, 180 sebaceous cysts of, 178 solid tumors of, 178 superficial structures, infection of, 160 traumatic aneurysms of, 152 tumors of, 172 auscultation and percussion, 174 classification, 174 examination, 172 of blood, spleen, mouth, and body in general, 173 inspection, 172 palpation, 173 unilocular cysts of, 177 veins of, injuries, 154 woody phlegmon of, 161 Necrosis, phosphorus, of jaws, 121 Nerve, auditory, injury, in fracture of base of skull, 30 circumflex, injury of, 435 eleventh, injury, in fracture of base of skull, 31 facial, injury of, 139 fourth, injury, in fracture of base of skull, 30 hypoglossal, injury, in fracture of base of skull, 31 median, injury of, 437 musculospiral, injury of, 435 ninth, injury, in fracture of base of skull, olfactory, injury, in fracture of base of skull, 30 optic, injury, in fracture of base of skull, 3° peroneal, injury of, 438 popliteal, external, injury of, 438 sciatic, and branches, injury of, 438 sixth, injury, in fracture of base of skull, 3° tenth, injury, in fracture of base of skull, 31 third, injury, in fracture of base of skull, 3° trigeminal, injury, in fracture of base of skull, 31 twelfth, injury, in fracture of base of skull, 31 ulnar, injury of, 437 Nerves, injuries of, 433, 435 in dislocations, 457 in fractures, 443 of base of skull, 28 of extremities, diseases of, 573 INDEX. 767 Nerves of extremities, tumors of, 574 of neck, injuries of, 154 Nervous system, diseases of, leukocytosis in, 724 Neuralgia, trigeminal, loi Neuralgic joints, 626 Neuritis of extremities, 573 optic, in abscess of brain, 83 in brain tumors, 75 in purulent leptomeningitis, 81 Neuromata dolorosa of extremities, 574 multiple, of extremities, 575 traumatic, of extremities, 574 Neuropathic arthritis, 621 Nevus, pigmented, of abdomen, 233 Ninth nerve, injury, in fracture of base of skull, 31 Nitze's cystoscopes, 737 Nodes, Heberden's, in arthritis deformans, 615 Noma, 95, 123 Nose, escape of blood from, in fracture of base of skull, 27 saddle-, due to syphilis, 97 Obstructed hernia, 402 Obstruction, intestinal, 277. See also Intestinal obstruction. Obturator hernia, 421 Occipital lobe, lesions, 47 tumors of, 77 Odontoma of jaws, 109 Olfactory nerve, injury, in fracture of base of skull, 30 Omentum, multiple abscess of, 255 puckering of, 343 tumors of, 310 Opsonic index, 719 abnormal, 719 effect of bacterial infections on, 719 Opsonins, 716 technic of measuring quantity, 718 Optic nerve, injury, in fracture of base of skull, 30 neuritis in abscess of brain, 83 in brain tumors, 75 in purulent leptomeningitis, 81 Orchitis, gonorrheal, 392 Os calcis,'fractures of, 521 innominatum, sarcoma of, 323 Osteitis deformans, 592 Osteoarthropathie pneumatique, 592 Osteoma of extremities, 595 of jaws, no of neck, 178 of skull, 72 Osteomalacia of extremities, 589 differential diagnosis, 590 Osteomyelitis, acute infective, of extremi- ties, 578 of ribs, 202 of skull, 70 of spine, 691 of sternum, 203 suppurative, of extremities, 578, 579 differential diagnosis, 581 Osteomyelitis, acute suppurative, of jaws, 121 gummatous, of extremities, 587 in fractures, 443 leukocytosis in, 723 Osteoporosis, fracture associated with, 441 Otitic cerebral abscess, 83 Ovary, hernia of, in inguinal hernia, 409 tumors of, large, 324 pedunculated, 324 torsion of pedicle, 273 differential diagnosis, 274 Pachymeningitis haemorrhagica interna, 55 purulent, 56 Pain as early sign of acute abdominal affections, 256 in appendicitis, 256 in carcinoma of stomach, 335 in coxa vara, 651 in fractures, 448 of pelvis, 489 in gallstone colic, 264 in intestinal obstruction, 278 strangulation, 279 in intussusception, 281 in malignant tumors of kidney, 316 in perforating ulcers of stomach and duodenum, 266 in Pott's disease, 687 in renal calculus, 367 in tuberculosis of joints, 612 of kidney, 365 in tuberculous gonitis, 642 in ulcer of stomach, 332 in volvulus, 280 location of, in tuberculous coxitis, 636 referred, from spinal and thoracic con- ditions, 276 Palate, diseases of, 103 tumors of, 127 Palpation in empyema, 209 in tuberculous coxitis, 632, 634 in tumors of abdomen, 288 of gallbladder region in gallstones, 339 of rectum, 345 results of, in renal calculus, 367 Pancreas, diseases of, leukocytosis in, 724 Pancreatic cysts, 301 differential diagnosis, 302 neoplasms, 303 differential diagnosis, 303 tumors, 299 Pancreatitis, acute, 270 differential diagnosis, 270 chronic, tumors due to, 299 Papillary wart on extremities, 556 Papilloma of larynx, 190 of tongue, 134 Paralysis, Brown-Sequard, 666 muscular, of extremities, 571 pseudo-, 621 Paraphimosis, 385 Paraplegia dolorosa in cancer of breast, 230 Parasites of bladder, cystoscopy in, 743 768 INDEX. Parathyroid glands, accessory, cysts of, 177 Parietal convolutions, ascending, lesions of, 44 lobe, lesions, 47 tumors of, 77 Parotid duct, injuries of, 139 gland, carcinoma of, 145 chondrosarcoma of, 144 injuries of, 138 tumors of, 145 Parotitis, coeliac, 141, 713 postoperative, 713 Patella, congenital dislocation, 648 dislocations of, 505 fractures of, 505 Patent urachus, cystoscopy in, 744 Patulency of ureter, 734 Pedicles of ovarian and uterine tumors, torsion, 273 differential diagnosis, 274 Pelvic lymph-nodes, neoplasms of, 323 peritonitis, leukocytosis in, 722 viscera, abdominal tumors having origin in, 323 of female, tumors of abdomen arising from, 323 Pelvis, fractures of, 488 abnormal mobility in, 489 pain in, 489 rupture of bladder in, 491 of urethra in, 490 Penis, congenital malformations of, 379 diseases and injuries of, 379 epithelioma of, 386 Percussion in empyema, 209 in tumors of abdomen, 289 Perforating ulcers of stomach and duode- num, 266 differential diagnosis, 267 dullness in flanks and right iliac region in, 267 facies in, 267 muscular rigidity in, 266 obliteration of liver dullness in, 266 pain in, 266 pulse in, 267 respiration in, 267 symptoms, 266 vomiting in, 266 of typhoid fever, 268 differential diagnosis, 269 Perforation in ulcer of stomach, 333 Pericarditis, suppurative, 217 Pericardium, penetrating injuries of, 200 subcutaneous injuries of, 198 Pericolitis sinistra, 255 Perigastric adhesions in gastric ulcer, 335 Perinephritis, 251 differential diagnosis, 252 Periosteal sarcoma of ribs, 207 Periostitis, acute infective, of extremities, 578 of skull, 70 traumatic, of extremities, 577 gummatous, of extremities, 587 Perirectal infection, 350 phlegmon, diffuse, 350 Perisinuous abscess, 80 Peristalsis in enterostenosis, 342 Perithelioma of bones of extremities, 594, 601 Peritoneal cavity, free fluid in, in injuries of alimentary canal, 241 Peritoneum, tumors of, 310 Peritonitis, acute, blood-pressure in, 731 gonorrheal, acute, 250 pelvic, leukocytosis in, 722 pneumococcus, 250 postoperative, 708 primary forms, 250 tuberculous, 343 abdominal tumors due to, 320 acute, 250 ascitic form, 344 differential diagnosis, 344 Peritonsillar abscess, 190 Pernicious anemia, examination of blood in, 728 Peroneal nerve, injury of, 438 Pertrochanteric fracture of Kocher, 498 Pes planus, 657 Pfeiffer's disease, 171 Phagocytic index of leukocyte, 718 Phagocytosis, 716 Phalanges, dislocations of, 486 fractures of, 486 of toes, fractures of, 522 Pharynx, diverticula of, 177 Phimosis, 385 Phlebitis of extremities, 561 postoperative, 711 Phlegmon, acute, of thoracic wall, 201 diffuse perirectal, 350 ligneux of Reclus, 161 of scalp, 66 woody, of neck, 161 Phlegmonous cholecystitis, 247 Phloridzin test, 748 Phosphorus necrosis of jaws, 121 Pia arachnoid, hemorrhage from smaller arteries of, 49 Pituitary body, tumor of, causing acromeg- aly, 79 Pleura, actinomycosis of, 216 subcutaneous injuries of, 196 tumors of, 212 Pleural fluids, cytodiagnosis of, 732 Plexus, brachial, injury of, 154, 437 Pneumococcus arthritis, 608 peritonitis, 250 Pneumonia in fractures, 444 in penetrating injuries of thorax, 200 leukocytosis in, 720 postoperative, 701, 702 Pneumothorax in penetrating injuries of thorax, 199 Podagra, 618 Poisoning from drugs, postoperative, 712 Poliomyelitis, anterior, deformities caused by, 654 INDEX. 769 Polycystic kidneys, 314 differential diagnosis, 314 Polydactylism, 661 Polyps of rectum, 359 Pons varolii, lesions of, 47 Pontomedullocerebellar space, tumors of, 77 Popliteal nerve, external, injury of, 438 Postoperative complications, 696 miscellaneous, 711 Pott's disease, 6S4 abscesses in, 688 deformity in, 6S7 differential diagnosis, 689 gibbus in, 688 pain in, 687 rigidity of spine in, 686 spinal cord symptoms, 689 fracture, 514 Pregnancy, extra-uterine, rupture of, 284 Prevesical abscess, 232 Previsceral suppuration in neck, 158 Proctitis, 349 acute, 349 chronic, 349 hypertrophic, 350 Prolapse of lung in penetrating injuries of thorax, 200 of rectum, 356 Prostate, affections of, 377 enlargement of, 377 differential diagnosis, 378 hypertrophy of, cytoscopy in, 740 Prostration in intussusception, 282 Pruritus ani, 349 Pseudarthrosis in fractures, 445 Pseudoleukemia, enlargement of cervical lymph-nodes in, 166 Pseudoparalysis, 621 syphilitic, 585 Psoriasis linguae, 129 Puckering of omentum, 343 Puerperal mastitis, acute, 221 Pulled elbow, 479 Pulse in appendicitis, 258 in perforating ulcers of stomach and duodenum, 267 in purulent leptomeningitis, 81 in pyemia complicating wounds, 539 in septicemia complicating wounds, 537 slow, in brain tumors, 75 Puncture, exploratory, in empyema, 210 lumbar, determining point for, 52 method of performing, 53 Purulent leptomeningitis, 56, 81 headache in, 81 optic neuritis in, 81 pulse in, 81 respiration in, 81 pachymeningitis, 56 Pus, localization of, in lower portion of genito-urinary tract, 381 instrumental examination in, 383 two-glass test for, 381 urethroscopy for, 384 Pyelitis, 362 49 Pyelonephritis, 251 differential diagnosis, 251 Pyemia com])licating wounds, 53S differential diagnosis, 540 Pylephlebitis, suppurative, 249 Pylorus, stenosis of, acquired, gastric dila- tation from, 332 congenital, gastric dilatation from, 331 Pyonephrosis, 252 Pyopericardium, 217 Rachioschisis, 662 Rachitic rosary, 591 Rachitis, 590 Radiographic examination in renal calcu- lus, 369 Radius and ulna, dislocation of, 477 backward, 477 dislocation of, 478 fractures of shaft, 479 of head and neck, 477 of lower end, 482 of upper end, 477 greenstick fracture of, 480 lesions of, 473 subluxation of, 479 Railway spine, 683 Ranula, acute, 125 chronic, 126 Rashes, septic, postoperative, 712 Raynaud's disease, gangrene of extremities due to, 553 Reclus, phlegmon ligneux of, 161 Rectal space, superior, abscess of, 352 Recti muscles of abdomen, suppuration in- sheath of, 231 Rectum, 345 abnormal opening of, 346 atresia of, 346 cancer of, 359 circumscribed suppuration of, 350 congenital malformations of, 346 cystic tumors behind, 695 examination of, 345 foreign bodies in, 348 history in examining, 346 inflammatory processes and results, 349 injuries of, 347 inspection of, 345 neoplasms of, 359 palpation of, 354 polyps of, 359 prolapse of, 356 stricture of, 357 differential diagnosis, 358 ulceration of, non-malignant, 354 use of specula in examining, 345 Referred pain from spinal and thoracic con- ditions, 276 Reproductive organs, male, infections of, 391 . . Respiration in perforating ulcers of stomach and duodenum, 267 in purulent leptomeningitis, 8r Retained testicle, 388 Retention-cysts of salivary glands, 141 //' IXDEX. Retromuscular suppuration in abdominal wall, 231 Rheumatism, acute articular, 605 leukoc}i;osis in, 721 of extremities, 570 chronic articular, 618 Rib, cervical, 148 Ribs, acute osteomyelitis of, 202 enchondroma of, 207 fractures of, 193 signs due to fractiu^e proper, 193 due to injur}' of intrathoracic viscera, 194 periosteal sarcoma of, 207 secondary,' tumors of, 207 tuberculosis of, 203 Rickets, 590 fetal, 591 Riva-Rocci sphygmomanometer, 38 Rodent ulcers of extremities, 557 Rosan,-, rachitic, 591 Rupture of bladder in fractures of pelvis, 491 of extra-uterine pregnancy, 284 of ligaments in traumatic arthritis, 453 of muscles, 426 of tendons, 426 of urethra, 380 in fractures of pelvis, 490 Sacrococcygeal sequestration dermoids, 695 teratomata, 695 tumors, 695 Sacroiliac joints, diseases of, 630 tuberculosis of, 630 Saddle-nose due to syphilis, 97 Salivary and lachr\-mal glands, symmetrical disease of, 98 calculus, 125, 140 ducts, cysts of, 142 fistula, 139 glands, affections of, 138 angioma of, 142 benign connective-tissue tumors of, 142 cysts of, 142 inflammatory affections of, 140 injuries of, 138 fibroma of, 142 lipoma of, 143 mixed tumors of, 143 retention-cysts of, 141 sarcoma of, 143 submaxillar}', solid tumors of, 125, 179 S}'philis of, 141 tuberculosis of, 141 tumors of, 141, 142 Salpingitis, leukocytosis in, 722 Sapremia complicating wounds, 536 Sarcoma, leukocytosis in, 725 of bones of extremities, 597 differential diagnosis, 600 fracture in, 600 myelogenous, 599 periosteal, 599 primary forms, 598 Sarcoma of bones of extremities, x-ray in, 600 of breast, 228 of extremities, 556 of face, loi of jaws, 113 of liver, 296 of muscles of extremities, 572 of neck, 179 arising from carotid body, 180 sheath, 180 of OS innominatum, 323 of salivary glands, 143 of scalp, 69 of skull, 72 of spleen, 306 of thorax, 206 of tongue, 134 periosteal, of ribs, 207 Scalp, angioma of, 68 cavernous, 68 arteriovenous aneur}-sm of, 69 carcinoma of, 69 cirsoid aneurysm of, 68 contused wounds of, 18 in infants and young children, 18 in older children and adults, 20 dermoid cysts of, 67 diseases of, 65 erysipelas of, 66 fibroma of, 68 hemorrhages in, location, 18 infection of, 65 injuries of, 17 lipoma of, 67 lymph-nodes of, infection, 66 malignant tumors of, 69 penetrating wounds of, 17 phlegmon of, 66 pigmented moles of, 68 sarcoma of, 69 traumatic aneurysm of, 69 tumors of, 66 vascular tumors of, 68 warts of, 68 Scapula, fractures of, 465 Scarlatina, leukocytosis in, 721 postoperative, 711 Sciatic hernia, 421 nerve and branches, injury of, 43S Sclerosing myositis of extremities, 571 Scoliosis, 690 Scorbutic joints, 624 Scorbutus, 591 Scurfy, 591 Sebaceous cysts of extremities, 556 of face, 99 of neck, 17S glands of extremities, adenocarcinoma of, 557 , adenoma of, 556 of face, adenoma of, 99 Sensory aphasia, 48 Septic complications in fractures, 443 rashes, postoperative, 712 Septicemia complicating wounds, 537 differential diagnosis, 540 INDEX. 771 Septicemia, leukocytosis in, 721 Septicopyemia complicating wounds, 538 Septum, nasal, injuries of, 87 Sequestration dermoids, sacrococcygeal, 695 Shock, 525 blood-pressure in, 730 characteristic signs of, 526 in intestinal strangulation, 280 in volvulus, 280 postoperative, 699 Shoulder, congenital dislocation, 648 injuries of, differential diagnosis, 460 region, dislocations in, 461 fractures in, 461 Shoulder-joint, diseases of, 627 dislocations of, 470 backward, 472 subspinous forms, 472 tuberculosis of, 628 Sigmoid sinus, thrombosis of, 85 Sinus, cavernous, thrombosis of, 85 cranial, thrombosis of, 84 sigmoid, thrombosis of, 85 thrombosis, intracranial, 59 Sinuses, venous, of brain, hemorrhage from, 49, 53 Sixth nerve, injur)', in fracture of base of skull, 30 Skin, injuries of, 423 Skull, acute osteomyelitis of, 70 periostitis of, 70 congenital defects of, 71 diseases of, 69 echinococcus of, 72 fractures of, 22. See also Fractures of skull. injuries of, 17 mental conditions following, 64 middle fossa of, tumors of, 78 osteoma of, 72 sarcoma of, 72 syphilis of, 69 tenderness of, in brain tumors, 76 tuberculosis of, 69 tumors of, 72 Sounds, examination of ureter with, 732 Specula, use of, in examining rectum, 345 Speech region, lesions of, 47 Spermatic-cord, torsion of, 274 Spermatocele, 399 Sphygmomanometer, Riva-Rocci, 38 Spina bifida, 662 Spinal conditions, referred pain from, 276 cord symptoms of Pott's disease, 689 tumors of, 692 localization, 666 Spine, acute osteomyelitis of, 691 arthritis deformans of, 691 concussion of, 683 cross-lesions of, table of symptoms in, 669-675 diseases and injuries of, 662, 684 dislocations of, 679 pathology, 664 fractures of, 676. See also Fractures oj spine. Spine, gunshot wounds of, 684 hysterical, 692 injuries of, 664 pathology, 664 lateral curvature, 690 raUway, 683 rigidity of, in Pott's disease, 686 stab wounds of, 684 tumors of, 692 typhoid, 692 Spleen, enlargements of, 305 floating, 304 hydatid cysts of, 306 sarcoma of, 306 tumors of, 304 wandering, 304 Spondylitis deformans, 6gi traumatic, 683 tuberculous, 684. See also Pott's disease. Sprains, 453 of elbow, 473 Sputum, examination of, 732 Stab wounds of spine, 684 Status thymicus, postoperative, 713 Stellwag's symptom of exophthalmic goiter, 189 Steno's duct, wounds of, 86 Stenosis of pjdorus, acquired, gastric dilata- tion from, 332 congenital, gastric dilatation from, 331 symptoms of, in cancer of intestine, 308 Sternum, acute osteomyelitis of, 203 fractures of, 194 secondary tumors of, 207 tuber ci-dosis of, 203 Still's disease, 617 Stomach, carcinoma of, 335. See also Car- cinoma oj stomach. contents, examination of, 732 dilatation of, 331, 332 from acquired stenosis of pylorus, 332 from congenital stenosis of pylorus, postoperative, 706 diseases of, postoperative, 704 hour-glass, in ulcer of stomach, 334 inflation of, in tumors of abdomen, 289 surgical diseases of, 331 tumors of, 289 differential diagnosis, 290 ulcer of, 332. See also Ulcer oj stomach. perforating, 266. See also Ulcer, per- jorating, oj stomach. Stomatitis, 123 gangrenous, 123 ulcerative, 123 Strangulated hernia, 403 Strangulation, intestinal, 279. See also Intestinal strangulation. Stricture of esophagus, 324 carcinomatous, 328 cicatricial, 328 due to pressure from external causes, 328 methods of examination, 325 spasmodic, 329 772 INDEX. Stricture of rectum, 357 differential diagnosis, 358 of ureter, 734 Subacromial dislocation, 472 Subastragaloid dislocations, 518 Subclavian artery, aneurysm of, 153 injury of, 152 Subclavicular dislocation, 472 Subcoracoid dislocation, objective signs, 471 Subcortical regions, lesions of, 47 Subcutaneous tissue, infection of, compli- cating wounds, 531 Subdural hemorrhage, 52 suppuration, 56 Subglenoid dislocations, symptoms of, 472 Subluxation of cartilages in traumatic ar- thritis, 453 of radius, 479 Submaxillary gland, salivary, solid tumors of, 125, 179 solid tumors of, 179 region, infection in, 158 Subperiosteal fractures, 441 Subphrenic abscess, 253 differential diagnosis, 254 left, in ulcer of stomach, 334 Subungual infection complicating wounds, 532 Supernumerary digits, 661 Suppuration as early sign of acute abdominal affections, 246 circumscribed, of rectum, 350 in abdominal wall, 231 in carotid sheath space, 159 in sheath of recti muscles of abdomen, 231 intracranial, following injuries, 55 mastoid, intracranial complications of, 80 metastatic, of kidney, 252 middle ear, intracranial complications, 80 previsceral, in neck, 158 retromuscular, in abdominal wall, 231 subdural, 56 Suppurative pericarditis, 217 pylephlebitis, 249 Supracondyloid fracture of humerus, 474 Supraorbital nerves, method of making pressure on, 29 Sweat glands of extremities, adenocarci- noma of, 557 adenoma of, 556 of face, adenoma of, 99 Swelling in tuberculosis of joints, 612 in tuberculous coxitis, 636 gonitis, 642 Symmetrical disease of lachrymal and sali- vary glands, 98 Syndactylism, 661 Synovitis, chronic serous, 605, 614 . Syphilis, acquired, of bones of extremities, 586 leukocytosis in, 728 nasal deformity due to, 98 of bladder, cystoscopy in, 744 of bones of extremities, 584, 585 of thorax, 205 of face, 96 Syphilis of jaws, 120 of liver, 296 of mouth, 124 of salivary glands, 141 of skull, 69 of testicle, 398 of tongue, 130 saddle-nose due to, 97 tertiary, ulcerations on back in, 201 Syphilitic arthritis, 619. See also Arthritis, syphilitic. atrophy of tongue, 133 bursitis of extremities, 567 lesions, secondary, of tongue, 131 tertiary, of tongue, 131 lymph-node enlargement of neck, 168 myositis, of extremities, 571 pseudoparalysis, 585 ulcerations of lip, 105 ulcers of extremities, 545 Syringomyelia, arthritis due to, 624 Tabes, arthritis due to, 622 Talipes calcaneus, 657 cavus, 657 equinovarus, 656 equinus, 656 valgus, 657 Tarsal bones, fractures of, 519 Teeth, infection of jaws from, 118 Temperature in appendicitis, 259 in tuberculosis of joints, 613 Temporo-maxillary joint, ankylosis of, 122 chronic arthritis of, 122 diseases of, 122 primary acute arthritis of, 122 secondary acute arthritis of, 122 Temporo-sphenoidal abscess, 83 Tenderness in appendicitis, 257 in gallstone colic, 264 in tuberculosis of joints, 612 Tendons and muscles of forearm and arm, infection between, complicating wounds, 532 dislocations of, 427 injuries of, 424 of extremities, diseases of, 567 inflammatory affections of, 567 tumors of, 570 penetrating wounds of, 428 rupture of, 426 Tendon-sheaths, infection along, compli- cating wounds, 532 injuries of, 424 of extremities, diseases of, 567 inflammatory affections of, 567 tumors of, 570 penetrating wounds of, 428 Tenesmus in intussusception, 282 Tenosynovitis, acute primary, of extremi- ties, 567 serofibrinous, of extremities, 567 seropurulent, of extremities, 568 secondary, of extremities, 568 chronic, of extremities, 568 serous, of extremities, 568 INDEX. 773 Tenosynovitis, chronic syphilitic, of ex- tremities, 570 crepitans, of extremities, 567 of extremities, 567 tuberculous, of extremities, 568 Tenovaginitis of extremities, 567. See also Tenosynovitis. Tenth nerve, injury, in fracture of base of skull, 31 Teratoma, sacrococcygeal, 695 Test, phloridzin, 748 tuberculin, in tuberculosis of joints, 613 two-glass, for pus in genito-urinary tract, 381 Testicle, 387 abnormalities in development of, 387 benign adenocystoma of, 399 ectopia of, 388 hernia of, in connection with imperfect descent, 391 hydrocele of, in connection with imperfect descent, 391 imperfect descent of, 388 complications, 388 hernia and hydrocele in connection with, 391 inflammation in, 389 tumor formation in, 390 inflammation of, in imperfect descent, 389 mixed tumors of, 400 neoplasms of, 399 retained, 388 syphilis of, 398 traumatic affections of, 393 tuberculosis of, 393 tumor formation of, in imperfect descent, 391 tumors of, 399 Tetanus, 122, 540 cephalic, 541 complicating wounds, 540 differential diagnosis, 541 head, 541 hydrophobicus, 541 symptomatic, 122 T-fractures of lower end of humerus, 474 Third nerve, injury, in fracture of base of skull, 30 Thoma-Zeiss blood-counting apparatus, 716 Thoracic aneurysm, 207 conditions, referred pain from, 276 duct, injuries of, 155 subcutaneous injuries of, 198 viscera, injuries of, 195 non-penetrating or subcutaneous inju- ries of, 195 wall, actinomycosis of, 202 acute and chronic inflammatory pro- cesses of, 201 phlegmon of, 201 skin and subcutaneous tissues of, in- flammatory processes, 201 tumors of, 206 Thorax, 193 bones of, syphilis, 205 bony, affections of, 202 Thorax, bony walls of, injuries, 193 fibroma of, 206 lipoma of, 206 penetrating injuries of, 199 dyspnea and cyanosis in, 200 emphysema in, 200 empyema in, 200 hemothorax in, 199 pneumonia in, 200 pneumothorax in, 199 prolapse of lung in, 200 pigmented moles of, 206 sarcoma of, 206 Throat, cut-, 156 Thrombophlebitis of extremities, 562 Thrombosis in fractures, 442 of cavernous sinus, 85 of cranial sinus, 84 of extremities, 561 of mesenteric vessels, 272 differential diagnosis, 273 of sigmoid sinus, 85 postoperative, 710 sinus, intracranial, 59 Thyroglossal cysts, 126, 176 fistula, 147 Thyrohyoid bursae, 177 Thyroid adenoma, 186 gland, accessory, cysts of, 177 Thyroidism, acute, postoperative, 714 Thyroiditis, 188 Tibia, fractures of lower end, 514 of shaft, 510 of upper end, 506 Tibiotarsal dislocations, 516 Tissues, air in, in fracture of base of skull, ^7. . . soft, injuries of, 422 signs, 423 Toes, dislocations of, 524 phalanges of, fractures, 522 Tongue, 127 benign tumors of, 133 carcinoma of, 134 differential diagnosis, 135 chancre of, 130 congenital affections of, 127 decubital ulcers of, 128 goiter of, 137 hemangioma of, 133 injuries of, 128 lipoma of, 133 lymphangioma of, 134 malignant tumors of, 134 mucous patches on, 131 papilloma of, 134 psoriasis of, 129 sarcoma of, 134 syphilis of, 130 syphilitic atrophy of, 133 lesions of, secondary, 131 tertiary, 131 tonsil of, 137 tuberculosis of, 130 Tongue-tie, 127 Tonsil, lingual, 13S 774 INDEX. Torsion of pedicles of ovarian and uterine tumors, 273 differential diagnosis, 274 of spermatic cord, 274 Trachea, foreign bodies in, 156 fractures of, 155 Trigeminal nerve, injur)', in fracture of base of skull, 31 neuralgia, loi Trismus, 122, 540. See also Tetanus. Trochanter, great, fracture of, 498 Trophic ulcers of extremities, 546 Tropical abscess, 248 differential diagnosis, 248 Tuberculin test in tuberculosis of joints, 613 Tuberculosis, ileocecal, inflammatory tu- mors of intestine from, 307 leukocytosis in, 727 of ankle-joint, 645 differential diagnosis, 645 of bladder, 374 cystoscopy in, 739 of bones of extremities, 582 of breast, 225 of elbow-joint, 628 of hip-joint, 632 differential diagnosis, 637 history, 633 inspection in, 632, 633 location of pain in, 636 measurements in, 636 palpation in, 632, 634 swelling in, 636 x-ray examination in, 637 of jaws, 119 of joints, 611 differential diagnosis, 613 family and personal history, 613 fungous form, 612 loss of function and rigidity in, 612 onset and course, 612 pain in, 612 position of limb in, 612 swelling in, 612 temperature in, 613 tenderness in, 612 tuberculin test in, 613 ;v-rays in, 613 of kidney, 363 cystoscopic examination in, 365 increased frequency of urination in, 364 pain in, 365 renal enlargement in, 365 symptoms, 364 general, 365 _ _ ureteral catheterization in, 365 urinary changes in, 364 of knee-joint, 641 abscess, sinus formation, and fever in, 643 differential diagnosis, 643 heat in, 642 pain in, 642 rigidity, atrophy, and deformity in, 642 swelling in, 642 tenderness in, 642 x-ray examination in, 643 Tuberculosis of ribs, 203 of sacroiliac joint, 630 of salivary glands, 141 of shoulder-joint, 628 of skull, 69 of sternum, 203 of testicle, 393 of tongue, 130 Tumor albus, 642 Tumors, benign, of bones of extremities, 594 connective-tissue, of salivary glands, 142 of breast, 227 of face, 98 of jaws, 108 of tongue, 133 cystic, behind rectum, 695 of neck, 174 due to chronic pancreatitis, 299 granulation-tissue, of jaws, 11 1 inflammatory, of intestine, 307 from ileocecal actinomycosis, 307 tuberculosis, 307 intestinal obstruction from, 282 history of, 282 malignant, of breast, 228 of extremities, 556 of epithelial type, 557 of face, 100 of jaws, 113 of kidney, 315. See also Kidney, mal- ignant tumors of. of liver, 296 differential diagnosis, of scalp, 69 of tongue, 134 mixed, of salivary glands, of testicle, 400 of abdomen, 285. See also Abdomen, tumors oj. of abdominal wall, 233 of bladder, 376 wall, cystoscopy in, 742 of bones of extremities, 593 of brain, 75. See also Brain, tumors of. of breast, 227 differential diagnosis, 230 of cerebellum, 77 of chest wall, 206 of epididymis, 399 of frontal lobe, 76 of gallbladder, 297 difl'erential diagnosis, 298 of inside of cheeks, 127 of intestine, 307 ■ of jaws, 108 of joints, 626 of kidney, 311 of liver, 291 of lungs, 217 of mediastinum, 219 of mesentery, 310 of middle fossa of skull, 78 of motor region of brain, 76 of muscles of extremities, 572 of neck, 172. See also A'ec/c, tumors of. of nerves of extremities, 574 297 143 INDEX. 775 Tumors of occipital lobe, 77 of omentum, 310 of ovary, large, 324 pedunculated, 324 torsion of pedicles, 273 differential diagnosis, 274 of palate, 127 of pancreas, 303 differential diagnosis, 303 of parietal lobe, 77 of parotid gland, 145 of peritoneum, 310 of pituitary body causing acromegaly, 79 of pleura, 212 of pontomedullocerebellar space, 77 of salivary glands, 141, 142 of scalp, 66 of skin and subcutaneous tissue of ex- tremities, 555 of skull, 72 of spinal cord, 692 of spine, 692 of spleen, 304 of stomach, 289 differential diagnosis, 290 of tendons of extremities, 570 of tendon-sheaths of extremities, 570 of testicle, 399 of umbUicus, 236 of uterus, pedunculated, 324 torsion of pedicles, 273 differential diagnosis, 274 pancreatic, 299 sacrococcygeal, 695 secondary, of ribs or sternum, 207 solid, of neck, 178 of submaxillary salivary gland, 125, 179 vascular, of scalp, 68 Twelfth nerve, injury, in fracture of base of skull, 31 Two-glass test for pus in genito-urinary tract, 381 Tympanites in enterostenosis, 342 in injuries of alimentary canal, 241 Typhoid fever, leukocytosis in, 720 perforation, 268 differential diagnosis, 269 spine, 692 Typhoidal arthritis, 608 Ulcer, blastomycotic, of extremities, 546 cystitic, cystoscopy in, 739 decubital, of extremities, 548 of tongue, 128 dental, 128 duodenal, 332. See also Ulcer 0} stom- ach. of bladder, cystoscopy in, 739 of stomach, 332 complications, 333 differential diagnosis, 333 dyspeptic symptoms in, 333 hemorrhage in, 333 hour-glass stomach in, 334 left subphrenic abscess in, 334 leukocytosis in, 723 Ulcer of stomach, nausea in, 333 pain in, 332 perforation in, 333 perigastric adhesions in, 335 symptoms, 332 vomiting in, 333 perforating, of duodenum, 266 differential diagnosis, 267 dullness in flanks and right iliac region in, 267 muscular rigidity in, 266 obliteration of liver dullness in, 266 pain in, 266 pulse in, 267 symptoms, 266 vomiting in, 266 of stomach, 266 differential diagnosis, 267 dullness in flanks and right iliac region in, 267 muscular rigidity in, 266 obliteration of liver dullness in, 266 pain in, 266 pulse in, 267 symptoms, 266 vomiting in, 266 of typhoid fever, 268 dift'erential diagnosis, 269 rodent, of extremities, 557 syphilitic, of extremities, 545 traumatic, of extremities, 544 trophic, of extremities, 546 tuberculous, of extremities, 547 varicose, of leg, 545 Ulceration of lip, 105 of rectum, non-malignant, 354 on back in tertiary syphilis, 201 Ulcerative stomatitis, 123 Ulna and radius, dislocation of, 477 backward, 477 fracture of shaft, 479 of upper end, 477 greenstick fracture of, 480 lesions of, 473 Ulnar nerve, injury of, 437 Umbilical hernia, 417. See also Hernia, umbilical. Umbilicus, abscess discharging through, 256 tumors of, 236 Ungual infection complicating wounds, 532 Urachus, malformations in connection with, 236 patent, cystoscopy in, 744 Ureter, examination of, in renal calculus, .370 with sounds, 732 patulency of, 734 stricture of, 734 Ureteral catheterization, 732 in tuberculosis of kidney, 365 concretions, 735 Ureter-cystoscope, Brenner's, 737 Urethra, congenital malformations of, 379 contusion of, 380 diseases and injuries of, 379 rupture of, 380 in fractures of pelvis, 490 776 INDEX. Urethroscopy for localization of pus in genito-urinary tract, 384 Urinary changes in renal calculus, 367 in tuberculosis of kidney, 364 organs, injuries of, symptoms, 241 system, diseases of, leukocytosis in, 724 Urine, crj^oscopy of, 747 electric conductivity of, 748 examination of, 732 in renal and vesical lesions, 361 in acute cystitis, 373 Urosepsis, 251, 373 Uterus, myoma of, large, 324 tumor of, pedunculated, 324 torsion of pedicle, 273 differential diagnosis, 274 Varicose ulcers of leg, 545 veins of extremities, 562 complications, 563 Vas deferens, inflammation of intra-abdom- inal portion, 276 Veins, injuries of, 432 of extremities, diseases of, 561 of neck, injuries of, 154 varicose, of extremities, 562 complications, 563 Ventral hernia, 420 Vermiform appendix, hernia of, in inguinal hernia, 409 Vertebrffi, dislocations of, 679 pathology, 664 fractures of, 676. See also Fractures of spine. lumbar, fractures of, 678 Vertebral arteries, injuries of, hemorrhage from, 50 artery, injury of, 152 Vertigo in brain tumors, 76 Viscera, abdominal, injuries of, 237. See also Abdominal viscera, injuries of. thoracic, injuries of, 194 non-penetrating or subcutaneous in- juries of, 195 Visceral crises, 274 Visual aphasia, 48 Volvulus, 280 constipation in, 280 examination of abdomen in, 280 nausea in, 280 pain in, 280 previous histor}% 280 shock in, 280 vomiting in, 280 Vomiting after operation, 70 accompanying symptoms, 705 character of vomitus, 705 length of time, 704 in appendicitis, 257 in cancer of stomach, 335 in gallstone colic, 264 in injuries of alimentary canal, 240 in intestinal obstruction, 278 strangulation, 280 in intussusception, 282 in perforating ulcers of stomach and duo- denum, 266 Vomiting in tumors of brain, 75 in ulcer of stomach, 333 in volvulus, 280 Vomitus, character of, in postoperative vomiting, 705 von Graefe's symptom in exophthalmic goiter, 189 Wandering spleen, 304 Warts of scalp, 68 papillar}', on extremities, 556 Webbed fingers, 661 White matter of brain, lesions, 47 Woody phlegmon of neck, 161 Word-deafness, 48 Wounds, anthrax complicating, 543 edema complicating, 543 cellulitis of finger or hand complicating, 531 contused, of scalp, 18 in infants and 3'oung children, 18 in older children and adults, 20 emphysematous cellulitis complicating, 534 epidermal infection complicating, 531 erj'sipelas complicating, 535 erysipeloid complicating, 536 glanders complicating, 543 gunshot, of spine, 684 hydrophobia complicating, 542 infection along tendon-sheaths compli- cating, 532 between muscles and tendons of fore- arm and arm complicating, 532 in lower extremities complicating, 534 of cutaneous and subcutaneous tissues complicating, 531 infective complications of, 529 lockjaw complicating, 540 malignant edema complicating, 534 of bladder, 372 of Steno's duct, 86 of upper extremities, local infections in, 530 penetrating, of muscles, 428 of scalp, 17 of tendons, 428 of tendon-sheaths, 428 pyemia complicating, 538 differential diagnosis, 540 sapremia complicating, 536 septicemia complicating, 537 differential diagnosis, 540 septicopyemia complicating, 538 stab,' of spine, 6S4 subungual infection complicating, 532 tetanus complicating, 540 ungual infection complicating, 532 ^ Wrist, dislocations of, 484 ganglion of, 570 Wrist-drop, 436 Wrist-joint, diseases of, 629 injuries in vicinity of, 480 Wry-neck, 150 Y-FRACTURES of lower end of humerus, 474 SAUNDERS' BOOKS on Nervous and Mental Diseases, Children, Hygiene, Nursing, and Medical Jurisprudence W. 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SAUNDERS' BOOKS ON Friihwald and WestcottV iseases of Children Diseases of Children. A Practical Reference Book for Students and Practitioners. By Professor Dr. Ferdinand Frlthwald, of Vienna. Edited, with additions, by Thompson S Westcott, M. D., Associate in Diseases of Children, University of Pennsylvania. Octavo volume of 533 pages, containing 176 illustrations. Cloth, $df.SO net. JUST READY This work represents the author' s twenty years' experience, and is intended as a practical reference work for the student and practitioner. With this refer- ence feature in view, the individual diseases have been arranged alphabetically. The prophylactic, therapeutic, and dietetic treatments are elaborately discussed. The practical value of the book has been considerably enhanced by the many excellent illustrations. E. H. Bartley. M. D,. Professor of Pediatrics, Chemistry , and Toxicology, Long Island College Hospital, New York. 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Galbraith*s Four Epochs of Woman's Life Second Revised Edition— Recently Issued The Four Epochs of Woman's Life: A Study in Hygiene. By Anna M. Galbraith, M. D., Fellow of the New York Academy of Medicine, etc. With an Introductory Note by John H. Musser, M. D., Professor of Clinical Medicine, University of Pennsylvania. i2mo volume of 247 pages. Cloth, $1.50 net. MAIDENHOOD. MARRIAGE, MATERNITY. MENOPAUSE In this instructive work are stated, in a modest, pleasing, and conclusive manner, those truths of which every woman should have a thorough knowledge. Written, as it is, for the laity, the subject is discussed in language readily grasped even by those most unfamihar with medical subjects. Binning>ham Medical Review, England " We do not as a rule care for medical books written for the instruction of the public. But we must admit that the advice in Dr. Galbraith's work is in the main wise and wholesome." Pyle*s Personal Hygiene A Manual of Personal Hygiene : Proper Living upon a Physiologic Basis. By Eminent Specialists. Edited by Walter L. Pyle, A. M., M. D., Assistant Surgeon to Wills Eye Hospital, Philadelphia. Octavo volume of 441 pages, fully illustrated. Cloth, ;$i.50 net. NEW (2d) EDITION-RECENTLY ISSUED The object of this manual is to set forth plainly the best means of developing and maintaining physical and mental vigor. It represents a thorough exposition of living upon a physiologic basis. In this new second edition there have been added new chapters on Home Gymnastics and Domestic Hygiene, besides an Appendi-x; of Emergency Procedures. Boston Medical and Surgical Journal ■• The work has been excellently done, there is no undue repetition, and the writers have succeeded unusually well in presenting facts of practical significance based on sound knpnti edge." SAUiXDERS' BOOKS OK Draper's Legal Medicine A Text=Book of Legal Medicine. By Frank Winthrop Draper, A. M., M. D., Professor of Legal Medicine in Harvard University, Bos- ton ; Medical Examiner of the County of Suffolk, Massachusetts, etc. Handsome octavo volume of 573 pages, fully illus. Cloth, $4.00 net. A NEW WORK— RECENTLY ISSUED The subject of Legal Medicine is one of great importance, especially to the general practitioner, for it is to him that calls to attend cases which mav prove to be medicolegal in character most frequently come. The medicolegal field includes not only deaths of a homicidal nature, but also suits at law — the fatal railway acci- dent, machinery casualties, and the like, to which the neighboring physician may be called, and later, perhaps, summoned to court. It is evident, therefore, that every practitioner should be thoroughly versed in all branches of medicolegal science. This volume, although prepared as a help to medical students, will be found no less valuable and instructive to practitioners. The author has had twenty-six years' experience as Medical Examiner for the city of Boston, his in- vestigations comprising nearly eight thousand deaths under a suspicion of violence. Hon. Olin Bryan. LL. B. Professor of Medical Jurisprudence, Baltimore Medical College " A careful reading of Draper's Legal Medicine convinces me of the excellent character of the work. It is comprehensive, thorough, and must, of a necessity, prove a splendid acquisition to the libraries of those who are interested in medical jurisprudence." Jakob and FisherV Nervous System and its Diseases Atlas and Epitome of the Nervous System and Its Diseases. By Professor Dr. Chr. Jakob, of Erlangen. Fnvn the Second Revised German Edition. Edited, with additions, by Edward D. Fisher, M. D., Professor of Diseases of the Nervous System, Universit}- and Bellevue Hospital [Medical College, New York. With 83 plates and copious text. Cloth, S3. 50 net. In Saunders' Hand-Atlas Series. The matter is divided into Anatomy, Pathology, and Description of Diseases of the Nervous System. The plates illustrate these divisions most completely ; especially is this so in regard to pathology. The exact site and character of the lesion are portrayed in such a way that they cannot fail to impress themselves on the memory of the reader. Philadelphia Medical Journal " We know of no one work of anything like equal size which covers this important and complicated field with the clearness and sciendfic fidelity of this hand-atlas." DISEASES OF CHILDREN. KerrV Diagnostics qf Diseases qf Children Diagnostics of the Diseases of Children. By LeGrand Kerr, M.D., Professor of Diseases of Children, Brooklyn Postgraduate Med- ical School, Brooklyn. Octavo of 550 pages, fully illustrated. JUST READY Dr. Kerr's work differs from all others on the diagnosis of diseases of children in that the objective syjnptotns are particularly emphasized. The author believes that as the objective symptoms are the main sources of information in diagnosing children's diseases, the subject should be discussed with these symptoms as the foundation. The constant aim throughout has been to render a correct diagnosis as early in the course of the disease as possible, and for this reason differential diagnosis is presented from the very earliest symptoms. The sequelae of the various diseases have been considered only to the extent that they may be of value in anticipating them and thus aiding in their early diagnosis. The physician will find the many original illustrations a source of much information and help. PAUL'S FEVER NURSING just issued Nursing in the Acute Infectious Fevers. By George P. Paul, M.D., Assistant Visiting Physician to the Samaritan Hospital, Troy, N. Y. i2mo of 200 pages. Cloth, $1.00 net. " The book is an excellent one and will be of value to those for whom it is intended. It is well arranged, the text is clear and full, and the illustrations are good." — The London Lancet. PAUL'S MATERIA MEDICA for NURSES Just issued Materia Medica for Nurses. By George P. Paul, M. D., Assistant Visiting Physician to the Samaritan Hospital, Troy. l2mo of 240 pages. Cloth, $1.50 net. Dr. Paul arranges the physiologic actions of the drugs according to the action of the drug and not the organ acted upon. An important section is that on pretoxic signs. AMERICAN TEXT-BOOK qf DISEASES qf CHILDREN second Edition American Text-Book of Diseases of Ciiii.nREN. Edited by Louis Starr, M.D., assisted by Thompson S. Westcott, M.D. Octavo, 1244 pages, profusely illustrated. Cloth, ^7.00 net ; Half Morocco, $8.00 net. SAUNDERS' BOOKS ON Friedenwald £f Ruhrah*s Dietetics for Nurses Dietetics for Nurses. By Julius Friedenwald, M. D., Clinical Professor of Diseases of the Stomach, College of Physicians and Sur- geons, Baltimore ; and John Ruhrah, M. D., Clinical Professor of Diseases of Children, College of Physicians and Surgeons, Baltimore. i2mo of 363 pages. Cloth, $1.50 net. JUST ISSUED This work has been prepared to meet the needs of the nurse, both in the training school and after graduation. It aims to give the essentials of dietetics, considering briefly the physiology of digestion and the various classes of foods and the part they play in nutrition. The subjects of infant feeding and the feeding of the sick are fully discussed, and rectal alimentation and the feeding of oper- ative cases are fully described. Diet-lists and recipes for the invalid's dietary are appended. Edinburg Medical Journal "It appears to us to contain all the practical side of dietetics, of handy size and de- void of padding." Lewis* Anatomy and Physiology for Nurses Anatomy and Pliysiology for Nurses. By LeRoy Lewis, M. D., Surgeon to and Lecturer on Anatomy and Physiology for Nurses at the Lewis Hospital, Bay City, Michigan. i2mo of 317 pages, with 146 illustrations. Cloth, $\.']^ net. JUST ISSUED The author has based the plan and scope of the work on the methods he has employed in teaching the subjects, and has made the text unusually simple and clear. The text is rendered more comprehensive by the practical illustrations, representing the best that could be obtained. Nurses Journal of the Pacific Coast " It is not in any sense rudimentary, but comprehensive in its treatment of the subjects in hand." NURSING. De Lee's Obstetrics for Nurses Obstetrics for Nurses. By Joseph B. De Lee, M.D., Professor of Obstetrics in the Northwestern University Medical School; Lecturer in the Nurses' Training Schools of Mercy, Wesley, Provident, Cook County, and Chicago Lying-in Hospitals. i2mo volume of 460 pages, fully illustrated. Cloth, $2.50 net. JUST ISSUED— NEW(2nd) EDITION The illustrations in Dr. De Lee's work are nearly all original, and represent photographs taken from actual scenes. The text is the result of the author's eight years' experience in lecturing to the nurses of five difterent training schools. J. Clifton Edgar, M. D., Professor of Obstetrics and Clinical Midwifery , Cornell Medical School, N. Y. " It is far-and-away the best that has come to my notice, and I shall take great pleasure in recommending it to my nurses, and students as well." Davis* Obstetric and Gynecologic Nursing Obstetric and Gynecologic Nursing. By Edward P. Davis, A.M., M. D., Professor of Obstetrics, Jefferson Medical College and Philadel- phia Polyclinic. i2mo of 400 pages, illustrated. Buckram, $1.7 S "et. RECENTLY ISSUED— SECOND REVISED EDITION The Lancet, London " Not only nurses, but even newly qualified medical men, would learn a great deal by a perusal of this book. It is written in a clear and pleasant style, and is a work we can recom- mend." Reference Handbook for Nurses A Reference Handbook for Nurses. By Amanda K. Beck, of Chicago, 111. 32nio of 177 pages. Flexible morocco, ^^1.25 net RECENTLY ISSUED This little book contains information upon every question that comes to a nurse in her daily work, and embraces all the information that she requires to carry out any directions given by the physician. Boston Medical and Surgical Journal "Must be regarded as an extremely useful book, not only for nurses, but for physicians." SAUNDERS' BOOKS ON Hofmann and Peterson's Le£(al Medicine Atlas of Legal Medicine. By Dr. E. von Hofmann, of Vienna, Edited by Frederick Peterson, M. D., Clinical Professor of Psychi- atry in the College of Physicians and Surgeons, New York. With 120 colored figures on 56 plates and 193 half-tone illustrations. Cloth, ^3.50 net. In Saunders' Hand-Atlas Series. By reason of the wealth of illustrations and the fidelity of the colored plates, the book supplements all the text-books on the subject. Moreover, it furnishes to every physician, student, and lawyer a veritable treasure-house of information. The Practitioner, London " The illustrations appear to be the best that have ever been published in connection with this department of medicine, and they cannot fail to be useful alike to the medical jurist and to the student of forensic medicine." Chapman's Medical Jurisprudence Medical Jurisprudence, Insanity, and Toxicology. By Henry C. Chapman, M. D., Professor of Institutes of Medicine and Medical Jurisprudence in Jefferson Medical College, Philadelphia. Handsome i2mo of 329 pages, fully illustrated. Cloth, ;$i.75 net. RECENTLY ISSUED— THIRD REVISED EDITION. ENLARGED This work is based on the author' s practical experience as coroner' s physician of the city of Philadelphia for a period of six years. Dr. Chapman's book, therefore, is of unusual value. This third edition has been thoroughly revised and greatly enlarged, so as to bring it absolutely in accord with the very latest advances in this important branch of medical science. There is no doubt it will meet with as great fa\-or as the previous editions. Medical Record, New York "The manual is essentially practical, and is a useful guide for the general practitioner, besides possessing literary merit." NURSING. 1 3 Golebiewski anc) Bailey's Accident Diseases Atlas and Epitome of Diseases Caused by Accidents. By Dr. Ed, Golebiewski, of Berlin. Edited, with additions, by Pearce Bailey, M.D., Consulting Neurologist to St. Luke's Hospital, New York. With 71 colored illustrations on 40 plates, 143 text-illustrations, and 549 pages of text. Cloth, 34.00 net. Li Saunders' Hand-Atlas Series. This work contains a full and scientific treatment of the subject of accident injury ; the functional disability caused thereb)' ; the medicolegal questions in- volved, and the amount of indemnity justified in given cases. The work is indispensable to every physician who sees cases of injury due to accidents, to advanced students, to surgeons, and, on account of its illustrations and statistical data, it is none the less useful to accident-insurance organizations. The MediceJ Record, New York " This volume is upon an important and only recently systematized subject, which is grow- ing in extent all the time. The pictorial part of the book is very satisfactory." Stoney*s Materia Medic a for Nurses Practical Materia Medica for Nurses, with an Appendix containing Poisons and their Antidotes, with Poison-Emergencies ; Mineral Waters ; Weights and Measures ; Dose-List, and a Glossary of the Terms used in Materia Medica and Therapeutics. By Emily M. A. Stonev, of the Carney Hospital, South Boston. i2mo of 300 pages. Cloth, $1.50 net. RECENTLY ISSUED— NEW (3rd) EDITION In making the revision for this new third edition, all the newer drugs have been introduced and fully discussed. The consideration of the drugs includes their sources and composition, their various preparations, physiologic actions, directions for administering, and the symptoms and treatment of poisoning. Journal of the American Medical Association " So far as we can see, it contains everything that a nurse ought to know in regard to drugs. As a reference-book for nurses it will without question be very useful." 14 SAUNDERS' BOOKS ON Stoney*s Nursing' Practical Points in Nursing: for Nurses in Private Practice. By Emily M. A. Stoney, Superintendent of the Training School for Nurses at the Carney Hospital. South Boston, Mass. 466 pages, fully illus- trated. Cloth, $1.7 S net. THIRD EDITION, THOROUGHLY REVISED— RECENTLY ISSUED In this volume the author explains the entire range of private nursing as dis- tinguished from hospital nursing, and the nurse is instructed how best to meet the various emergencies of medical and surgical cases when distant from medical or surgical aid or when thrown on her own resources. An especially valuable feature \vill be found in the directions how to improvise everything ordinarily needed in the sick-room. The Lancet, London "A very complete exposition of practical nursing in its various branches, including obstetric and gynecologic nursing. The instructions given are full of useful detail." Stoney 's Technic for Nurses Bacteriology and Surgical Technic for Nurses. By Emily M. A. Stoney, Superintendent at Carney Hospital, South Boston. Revised by Frederic R. Griffith, M. D., Surgeon, of New York. i2mo, 278 pages, illustrated. Cloth, ;^i.50 net. RECENTLY ISSUED— NEW (2d) EDITION Trzuned Nurse amd Hospital Review " These subjects are treated most accurately and up to date, without the superfluous reading which is so often employed. . . . Nurses will find this book of the greatest value both during their hospital course and in private practice." Spratling on Epilepsy Epilepsy and Its Treatment. By William P. Spratling, M. D., Medical Superintendent of the Craig Colony for Epileptics, Sonyea, New York. Octavo of 522 pages, fully illustrated. Cloth, ^4.00 net. The Lancet, London " Dr. Spratling's work is written throughout in a clear and readable style. . . . The work is a mine of information on the whole subject of epilepsy and its treatment." CHILDREN AND HYGIExXE. 15 Griffith*s Care of the Baby The Care of the Baby. By J. P. Crozer Griffith, M. D., Clinical Professor of Diseases of Children, University of Penn. ; Physician to the Children's Hospital, Phila. i2mo, 436 pp. Illustrated. Cloth, ^1.50 net, RECENTLY ISSUED— THIRD EDITION, THOROUGHLY REVISED The author has endeavored to furnish a reliable guide for mothers. He has made his statements plain and easily understood, in the hope that the volume may be of service not only to mothers and nurses, but also to students and practi- tioners whose opportunities for observing children have been limited. New York Medical Journal " We are confident if this little work could find its way into the hands of every trained nurse and of every mother, infant mortality vv^ould be lessened by at least fifty per cent." Crothers* Morphinism Morphinism and Narcomania from Opium, Cocain, Ether, Chloral, Chloroform, and other Narcotic Drugs ; also the Etiology, Treatment, and Medicolegal Relations. By T. D. Crothers, M. D., Superintendent of Walnut Lodge Hospital, Hartford, Conn. Handsome i2mo of 351 pages. Cloth, ^$2.00 net. The Lancet, London "An excellent account of the various causes, symptoms, and stages of morphinism, the discussion being throughout illuminated by an abundance of facts of clinical, psychological, and social interest." Abbott's Transmissible Diseases The Hygiene of Transmissible Diseases : Their Causation, Modes of Dissemination, and Methods of Prevention. By A. C. Abbott, M. D., Professor of Hygiene and Bacteriology, University of Pennsylvania. Octavo, 351 pages, with numerous illustrations. Cloth, ;$2.50 net. SECOND REVISED EDITION During the interval that has elapsed since the appearance of the first edition investigations upon the modes of dissemination of certain of the specific infections have been very active. The sections on Malaria, Yellow Fever, Plague, Filariasis, Dysentery, and Tuberculosis have been both revised and enlarged. The Lancet, London " We heartily commend the book as a concise and trustworthy guide in the subject with which it deals, and we sincerely congratulate Professor Abbott." i6 SAUNDERS' BOOKS ON CHILDREN. , •jtx'j* Fourth Edition, Revised American Pocket Dictionary Recently issued American Pocket jMedical Dictionary. Edited by W. A. New- man Borland, M. D., Assistant Obstetrician to the Hospital of the Unive'rsity of Pennsylvania. Containing the pronunciation and defini- tion of the principal words used in medicine and kindred sciences, with 64 extensive tables. Handsomely bound in flexible leather, with gold edges, $1.00 net; with patent thumb index, $1.25 net. " I can recommend it to our students without reserve." — J. H. HOLLAND, M. D., Dean of the Jefferson Medical College, Philadelphia. Morrow's Immediate Care of Injured just Ready Immediate Care of the Injured. B}- Albert S. Morrow, M. D., Attending Surgeon to the New York City Hospital for the Aged and Infirm. Octavo of 340 pages, with 238 illustrations. Cloth, $2.50 net. Dr. Morrow's book on emergency procedures is written in a definite and decisive style, the reader being told just what to do in every emergency. It is a practical book for everv day use, and the large number of excellent illustrations can not but make the treatment to be pursued in any case clear and intelligible. Physicians and nurses will find it indispensible. POWeirS Diseases of Children Third Edition, Revised Essentials of the Diseases of Children. By ^^'ILLIAM M. Powell, M. D. Revised by Alfred Hand, Jr., A. B., M. D., Dispensary- Physician and Pathologist to the Children's Hospital, Philadelphia. i2mo volume of 259 pages. Cloth, 31.00 net. /;; Saunders'' Question- Compend Series. Shaw on Nervous Diseases and Insanity PoSh^^Edltion Essentials of Nervous Diseases and Insanity : Their Symptoms and Treatment. A Manual for Students and Practitioners. By' the late John C. Shaw, M. D., Chnical Professor of Diseases of the Mind and Nervous System, Long Island College Hospital, New York. i2mo of 204 pages, illustrated. Cloth, $1.00 net. In Saunders' Question- Cof?i- pend Series. " Clearly and intelligently written ; we have noted few inaccuracies and several sug- gestive points. Some affections unmentioned in many of the large text-books are noted." — Boston Medical and Surgical Joiirfial. Starr's Diets for Infants and Children Diets for Infants and Children in Health and in Disease. By Louis Starr, M. D., Consulting Pediatrist to the INIaternity Hospital, Philadelphia. 230 blanks Tpocket-book size). Bound in flexible Morocco, ^1.25 net. Grafstrom's Mechano-Therapy seco^rRSd'clon A Text-book of Mechano-therapy (Massage and IMedical Gymnas- tics). By Axel V. Gr.a.fstrom, B. Sc, M. D., Attending Physician to the Gustavus Adolphus Orphange, Jamestown, New York. i2mo, 200 pages, illustrated. Cloth, Si. 25 net. COLUMBIA UNIVERSITY LIBRARIES This book is due on the date indicated below, or at the expiration of a definite period after the date of borrowing, as provided by the library rules or by special arrangement with the Librarian in charge. DATE BORROWED DATE DUE DATE BORROWED DATE DUE 1 j I 1 *%:■ fv ' ^"l-i ( ■•K C28(546)M25 RD °35^EI8^C T^'^^ LIBRARIES (hsl,stx) Surgical r!),:ia;iijsis 2002118203 RP5^ 6 A 5' I